Significant update on asthma management

Anastasia Tsirtsakis

28/08/2020 3:26:51 PM

Australian Asthma Handbook V2.1 focuses on avoiding the underuse of preventer medications and the over-reliance on reliever medications.

Illustration of lungs
The ‘Australian Asthma Handbook’ is designed to provide practical guidance for primary care professionals diagnosing and managing asthma.

The updated guidelines recommend as-needed low-dose budesonide-formoterol be used as an alternative to a daily maintenance low-dose inhaled corticosteroid preventer for the relief of symptoms in adults and adolescents aged over 12 with mild asthma.
The update is supported by four randomised controlled trials of close to 10,000 adults and adolescents. Results showed as-needed low-dose budesonide-formoterol provided immediate symptom relief and reduced the risk of severe flare-ups by two-thirds compared to using short-acting relievers alone.
Professor Amanda Barnard, a GP and Chair of the Guidelines Committee, told newsGP the recommendation gives GPs another option in step two of asthma management.
‘This approach [in clinical trials] addressed the underlying lung inflammation and resulted in better health outcomes than with a short-acting reliever alone,’ she said.
‘We’ve always said most people probably need to be on some form of inhaled steroids, and our only option was as a regular daily dose and then using a reliever as needed. So this has given us another option for those people with mild asthma.’

Professor Barnard did point out, however, that short-acting relievers such as salbutamol remain an essential rescue medicine for their role in management of acute asthma and community first aid.
‘It’s not going to suit everybody,’ she said. ‘Some people are very well controlled and very happy to take their daily doses.
‘They still provide safe relief of symptoms when used with a regular daily inhaled corticosteroid preventer.’
Other updated recommendations:

  • Adults over 18 with moderate-to-severe asthma requiring level 3–4 asthma treatment options can now use beclometasone–formoterol combination in a single inhaler as a daily maintenance treatment, or as a maintenance-and-reliever therapy
  • Adults and adolescents with severe asthma can use dupilumab, a new biological add-on therapy option
  • For children, or adults and adolescents whose inhaled corticosteroid dose has been tapered, a new lower strength fluticasone furoate 50 mcg can be used
One in nine Australians – 2.7 million people – have asthma, with the majority of cases diagnosed and treated in general practice.
Dr Kerry Hancock, Chair of the RACGP's Respiratory Medicine Specific Interests network, urged GPs to take the time to familiarise themselves with the updates.
‘Guidelines get updated and I think we can become a little bit complacent about checking those updates,’ she told newsGP. ‘But some of the recommendations in there are a significant change to how we can manage mild asthma.
‘So I would really like to emphasise that GPs look at these new guidelines and take them on board, review them and think about what implications they have for the way that they manage asthma now.’
Professor Barnard says the Australian Asthma Handbook is unique in that it is developed by primary care physicians, with specialist input, ensuring it is suitable for GPs’ everyday practice. 
‘What makes it really useful is the fact that it is online and it’s completely searchable,’ she said. ‘So if you’ve got a query, if you’re thinking, “Oh, I wonder what that is”, you can just type it in, find it and download the information.
‘We’ve also got the evidence that we’ve used – the links will actually take you to the original papers. So it’s a multi-layered resource.’
GPs will also find guidance on when and how to refer patients, as well as information on comorbidities. There is also a section on managing asthma during the COVID-19 pandemic.
‘As COVID is respiratory, there’s probably quite a bit of anxiety about any symptoms: “Is this my asthma getting worse or is it COVID?”,’ Professor Barnard said.
‘Somebody who’s getting increased chest tightness and cough, we’re urging them to see their doctor and discuss it and, if appropriate, get tested to try and work out what it is.
‘That initial telephone triage, depending on how the practice is set up, is important.’
Dr Hancock agrees. She says GPs in parts of Australia with significant community transmission first and foremost need to protect themselves with the appropriate personal protective equipment (PPE) when assessing patients with respiratory symptoms. Alternatively, she suggests using referral pathways to GP-led respiratory clinics, or to a GP with PPE.
‘It’s important that GPs don’t expose themselves unnecessarily,’ she said.
‘Any patient presenting with respiratory symptoms should be tested for COVID. But we also want those patients who are presenting with possible asthma flare-ups to be appropriately managed for asthma –not just to be tested for COVID.’
The Australian Asthma Handbook update also provides guidance and education for the implementation of the new guidelines.
‘It’s very important that we get the diagnosis right,’ Professor Barnard said.
‘That we assess people properly, work out the appropriate management, and keep reviewing them until we’ve got good control of their asthma symptoms. Essentially we want everybody with asthma to be able to lead the life they want to lead, with no restrictions from their asthma.’
GPs and other health professionals can register to attend the revised ‘Australian Asthma Handbook’ launch, taking place online on Tuesday 1 September at 6.30 pm.
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