Navigating the recent growth in asthma medications

Tim Robertson

7/06/2022 1:36:58 PM

The National Asthma Council Australia has launched new resources to help inform health professions about treatment options.

GP showing inhaler to patient
There is a growing number of asthma inhalers and devices becoming available.

According to National Asthma Council Australia Director and respiratory physician Professor Peter Wark, there has been a recent ‘explosion’ in the medications available for people with asthma.
But while the choice is welcome, it has made it more difficult for time-poor clinicians to stay up to date with the latest medications and their indications, which is why the council has released a new set of resources to help guide practitioners when determining the best treatment option.
The first resource is a chart that provides a visual reference of the medications for each level of the diagram from the Australian Asthma Handbook, which is designed to assist healthcare providers when selecting and adjusting medication for adults and adolescents.
‘The chart is popular with GPs and pharmacists as there … [are] so many different inhalers and devices on the market,’ Professor Wark said.
‘This presents a real challenge and can cause confusion for both patients and healthcare workers.
‘This chart now brings all of the information together in a visual format of medications and when to use them, in one place as a quick reference.
‘We hope that GPs and pharmacists will use this visual aid to help patients understand the place of their therapy and to reinforce the important place of preventer therapy in the management of almost everyone with asthma.’
The second resource is an updated version of the Asthma and Chronic Obstructive Pulmonary Disease (COPD) Medications chart, which offers a guide to the main types of asthma and COPD medications available in Australia.
The updated version also specifies the Pharmaceutical Benefits Scheme (PBS) reimbursement status of each medication as of April 2022.
The chart provides a quick reference guide that touches on the best approach to asthma and COPD and when to use the right inhalers at the right time, Professor Wark explained.
‘It is a useful education resource for health professionals to help with identification and explanation of different treatments,’ he said.
‘This is such a changing environment and keeping up to date is a major challenge, so it is important for GPs and pharmacists to keep informed about new medications and also existing medications where packaging or branding has changed.’
According to Professor Nick Zwar, Chair of the National Asthma Council Australia Guidelines Committee, the number of long-acting muscarinic antagonists (LAMAs) has also recently risen and there is a need to have the range of treatment options presented clearly in a single-page document.
‘It used to be just tiotropium and now there is umeclidinium, aclidinium and glycopyrronium,’ he told newsGP.
‘That is three additional LAMAs that have only fairly recently been available for treating more difficult to control asthma.’
The importance of presenting the information visually should also not be discounted, according to Professor Wark.
‘Even when patients don’t remember the name of their inhaler, they will recognise it,’ he said.
‘They can see where it should be placed in therapy and it is also an important aid for those when English is not their first language.
Compounding the issue of rapid growth in the number of LAMAs, inhaled corticosteroids (ICS), long-acting beta agonists (LABAs) and combinations of these medications, is that the same medication often comes in a variety of devices.
Professor Wark said that choosing the most appropriate device should be ‘a collaborative effort’ between the patient and their GP.
‘It is very important the patient is using a device they are comfortable with and they like. That has been shown to very clearly influence their adherence to that device,’ he said.
‘The use of the devices themselves are complex and require training, initiation, and support for the patient – and that support needs to be often an ongoing thing.
‘If someone is established on a certain type of device and they are shown how to use it, changing that device can be quite disruptive. That’s a challenge in the respiratory space.’
Moreover, diagnosing asthma has always been challenging because it usually requires lung function testing and spirometry to demonstrate reversible airflow obstruction.
‘This testing is time consuming, it is not well reimbursed and GPs are often not familiar with interpreting it,’ Professor Wark said.
‘There has been an underutilisation of the testing and, as a consequence, that has led to both an under- and an over-diagnosis of asthma. And, at times, inappropriate use of medication.’
These challenges have been further heightened by the pandemic because there is a risk that these procedures generate aerosols.
‘There was a very long period where virtually no lung function [testing] was happening,’ Professor Wark said.
‘There has been somewhat of a shift back towards doing it again, but in many cases there is still a reluctance in primary care to reintroduce spirometry, partly based on these [COVID-related risks].
‘While there are some alternative diagnostic tests, such exhaled nitric oxide, these are less well known and the equipment is less available in Australia.’
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Dr Ian Mark Light   8/06/2022 7:29:54 AM

In the Asthma Management Plans a Decade ago the Wrights peak flow meter was the means of measuring control with normal values written out according to Age Gender and Height taken at various times before and after bronchodilation therapy or when feeling “wheezy “ to direct treatment escalation .
The new Guideline is to use an inhaled cortisone with a short acting bronchodilator for relief of exacerbation on the background of usual medication.

Dr Richard Michael Hambour   9/06/2022 9:34:06 AM

Interesting to note that Breztri has been omitted from the triple therapy list in the "Asthma & COPD Medications" list. Even the Asthma Council has trouble keeping up!