Update to national asthma guidelines

Morgan Liotta

13/05/2022 1:41:45 PM

The Australian Asthma Handbook V2.2 includes information on exercise-induced bronchoconstriction, vaping and newly available medications.

Man inhaling asthma puffer
Several new asthma treatment products have been introduced to the PBS.

The National Asthma Council has updated its Australian Asthma Handbook with a version 2.2, to provide the most up-to-date and evidence-based practical guidance for primary healthcare professionals diagnosing and managing asthma in adults and children.
Professor Nick Zwar, Chair of the National Asthma Council Australia Guidelines Committee, told newsGP that although not a significant update, the new version will further help GPs in their role of asthma management.
Among the key updates is clinical guidance on the management of exercise-induced bronchoconstriction.
‘This is particularly trying to make sure that if someone’s getting more persistent asthma symptoms, that you might use an inhaled corticosteroid [ICS] medicine, and you might find after a few weeks, they didn’t need the pre-exercise short-acting beta agonist,’ Professor Zwar said.
‘That is a change from the previous advice, and people might use either a combination of a low-dose ICS or the low-dose ICS formoterol combination.’
The revision aligns with current recommendations on indications for initiating ICS treatment to include newer reliever options, and more detailed dosing information for single-inhaler combinations of ICSs and long-acting beta-2 agonist combinations.
Another notable update is to the clinical guidance on smoking and asthma management, covering the use of e-cigarettes for smoking cessation.

A revision of the recommendation to ‘not encourage’ the use of e-cigarettes, even for the purpose of smoking cessation, has been amended to:
‘Warn patients that e-cigarettes could cause lung damage and should not be used long term, and that the effects of vaping on asthma are not well enough understood to be safe for people with asthma.’ 
The handbook advises prescribers to refer to national guidance before prescribing nicotine for use in an electronic inhaler or vape.
Professor Zwar said these recommendations align with the RACGP’s smoking cessation guidelines, for which he is on the Expert Advisory Group.
‘We would say there is potentially a role – not as first-line therapy, but probably more last-line therapy – for using nicotine e-cigarettes to help people to stop smoking,’ he said.
He also points out that the efficacy and safety of nicotine e-cigarettes for supporting smoking cessation in people with asthma is unknown, and there are no specific studies on people with asthma.
‘There is a lack of evidence specifically in people with asthma,’ he said.
‘They certainly wouldn’t be considered as first line, but they may be an option in selected patients for short-term use in the same way as the RACGP guidelines [indicate].’
In addition to the treatment updates, a number of new asthma medicines have been introduced to the PBS:

  • Mometasone–indacaterol via dry-powder inhaler with capsule (Atectura Breezhaler)
  • Mometasone–indacaterol–glycopyrronium via dry-powder inhaler with capsule (Enerzair Breezhaler)
  • Budesonide–formoterol (BiResp Spiromax) – new generic
  • Salbutamol inhalers with dose-counters
  • Mometasone–olopatadine intranasal spray
‘These new products just didn’t exist before,’ Professor Zwar said.
‘They are combinations of ICSs with long-acting beta agonist – various forms – and there’s some information on those in the update, and about changes to PBS listings.’
In addition, the cromones nedocromil sodium and sodium cromoglycate have both been discontinued and are ‘no longer considered therapeutic options’, according to Professor Zwar.
The handbook’s recommendation that ‘sodium cromoglycate cromones can be considered for children who are unable to tolerate montelukast or where a nonsteroidal treatment option is preferred’ has been removed.
Minor amendments in V2.2 include to the roles of spirometry in clinical practice, salbutamol dose monitoring and reinforcement of key messages for written asthma action plans.
The handbook will continue to be reviewed and updated with latest recommendations, more information topics, tables and figures, as well as the revision of existing advice and information.
‘We’re already starting to work on some things with version three, which is a bigger job,’ Professor Zwar said.
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