AusPharm CPD
New Australian asthma guidelines
28/08/2014
New Australian asthma guidelines
The National Asthma Council 2014 Australian Asthma Handbook has important changes that every
pharmacist should be aware of. Some of the key changes in the Australian Asthma Handbook include:
• New diagnostic algorithms for adults and children • Updated stepped medical management
• Focus on inhaler technique and adherence • New acute asthma protocols.
Learning objectives
After completing this activity, pharmacists should be able to:
• Identify changes in the new edition of the Australian Asthma Handbook
• Assess control of asthma in adults and children
• Discuss when asthma medication should be stepped up or down
• Advise patients with asthma on lifestyle interventions and complementary therapies.
This activity has been accredited for 1 hour of Group One CPD (1 CPD Credit) that may be
converted to 2 Group Two CPD Credits upon successful completion of the corresponding
assessment for inclusion on an individual pharmacists CPD Record.
Accreditation number: A1408AP0.
The 2010 Competency Standards addressed by this activity include (but may not be limited to): 6.1, 6.2, 7.1,
7.2.
Author: Debbie Rigby B.Pharm, Grad Dip Clin Pharm, Adv Dip Nutr Pharm, CGP, AACPA, ASCP, FPS
Debbie Rigby is a consultant clinical pharmacist from Brisbane. Since graduation with a
Bachelor of Pharmacy from the University of Queensland she has since obtained a Graduate
Diploma in Clinical Pharmacy, Certification in Geriatric Pharmacy, Advanced Diploma in
Nutritional Pharmacy and certification as an Asthma Educator.
Debbie is the Chair of the Australian Association of Consultant Pharmacy (AACP) Board and
member of the National Advisory Group of AACP, as well as a Director of the National
Prescribing Service (NPS) Board. Debbie is also a Fellow of PSA and the American Society of Consultant
Pharmacists (ASCP). Academic appointments include Adjunct Senior Lecturer at University of Queensland
and James Cook University. She is also on the Australian & New Zealand Continence Journal Editorial
Committee.
Debbie has a special interest in geriatric pharmacotherapy and chronic disease self-management,
regularly conducts medication review services as an accredited pharmacist and provides many
presentations to pharmacists, nurses, general practitioners, allied health professionals and consumers.
In 2001 Debbie was awarded the PSA Australian Pharmacist of the Year, in 2002 the PSA Qld Bowl of
Hygeia and in 2008 was the inaugural recipient of the AACP Consultant Pharmacist Award.
AusPharm gratefully acknowledges the financial support provided
by the sponsors of our CPD program, MIMS
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AusPharm CPD
New Australian asthma guidelines
28/08/2014
New Australian asthma guidelines
The National Asthma Council 2014 Australian Asthma Handbook1
was released in May, with important changes that every pharmacist
should be aware of. The new guidelines are only available on-line at
www.asthmahandbook.org.au. The Australian Asthma Handbook –
Quick Reference Guide is a companion to the full Australian Asthma
Handbook. The Guide features key figures and tables from the Handbook, alongside selected section
overviews to provide context. It is not intended as a stand-alone summary of the guidelines. It is available
to download as a pdf or can be ordered online and is available from the two major sponsors, AstraZeneca
and Mundipharma.
A comparison between the Asthma Management Handbook 2006 and Australian Asthma Handbook 2014 is
also available here.
In addition, a consumer resource My Asthma Handbook, has been developed to support the 2014 national
treatment guidelines for asthma management. This is the first time a companion to the national guidelines
has been produced for people with asthma and their families.
Some of the key changes in the Australian Asthma Handbook include:
•
•
•
•
New diagnostic algorithms for adults and children
Updated stepped medical management
Focus on inhaler technique and adherence
New acute asthma protocols
Asthma statistics
Asthma affects about one in ten adults and one in 9 or 10 children in Australia. This is high compared to
international prevalence figures. Asthma is more common in Indigenous Australians, particularly adults,
than in other Australians.
New data from the Australian Bureau of Statistics (ABS) revealed that more than 60% of asthma deaths
occurred in people aged 75 and over. In total, 394 deaths were recorded in 2012 affecting 260 females and
134 males. Women over 75 years old are almost three times more likely to die from asthma compared to
their male counterparts.
Although up to one in seven older Australians have asthma, about half of all people with asthma aged 75
years and over have not been diagnosed by a medical practitioner.
Long-acting beta2-agonists (LABAs) are currently overprescribed in children. They are also often used
inappropriately as first-line therapy and are not recommended for children aged five years or less. A PBS
post-market review of medicines used to treat asthma in children has recently been released. It is evident
that the supply of fixed dose combination (FDC) with inhaled corticosteroids (ICS) and LABAs to children in
Australia is inconsistent with the observed epidemiology of asthma and guideline recommendations for
treatment. The draft report states that 79% of children (0-18 years) started treatment with a FDC product
without first trialling an inhaled corticosteroid or oral corticosteroid. A large number (59-79%) of children,
with no prior ICS use, had only one FDC prescription filled in a 12 month period. Over 25% of FDC
prescriptions are supplied to children below the age recommended in Australian clinical guidelines.
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New Australian asthma guidelines
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Source: Australian Institute of Health and Welfare, March 2014
Classes of asthma medicines
One of the most significant changes in the new handbook is the classification of medicines. Only two classes
of asthma treatment are now recognised:
•
•
Relievers
Preventers
The previous class of symptom controllers (LABAs) is no longer referred to, as LABAs should not be used
without inhaled corticosteroid in the management of asthma.
Role
Relievers
Pharmacological class
Short-acting beta2-agonist
Preventers
Inhaled corticosteroid/rapid-onset
long-acting beta2-agonist combination
Inhaled corticosteroid
Medications
Salbutamol
Terbutaline sulfate
Budesonide/eformoterol fumarate
dihydrate
Beclomethasone dipropionate
Budesonide
Ciclesonide
Fluticasone propionate
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Inhaled corticosteroid/ long-acting
beta2-agonist combinations
Leukotriene receptor antagonists
Cromones
28/08/2014
Budesonide/eformoterol fumarate
dihydrate
Fluticasone propionate/ eformoterol
fumarate dihydrate
Fluticasone propionate/salmeterol
xinafoate
Fluticasone furoate/vilanterol trifenatate
Montelukast
Sodium cromoglycate
Nedocromil sodium
Classification of asthma
Assessment of pattern of asthma (intermittent, mild persistent, moderate persistent, severe persistent) is
no longer recommended in adults, because it is not the best guide to treatment. Initial and ongoing
treatment is guided by an assessment of recent control, risk factors for flare-ups and medication-related
adverse effects.
In children, initial treatment is guided by the pattern and severity of asthma symptoms. Ongoing treatment
is based on recent asthma symptom control and risk factors. In the 2006 guidelines, the frequency of
symptoms (infrequent or frequent intermittent, persistent) determined the need for preventer therapy.
Continual assessment of asthma control is now a high priority. The decision to treat is now based on:
•
•
Current control
Risk of flare-up
What is good control?
One of the key changes in the 2014 Australian Asthma Handbook is a shift from assessing the severity of
asthma to guide treatment towards control of asthma. Continual assessment of asthma is now the priority.
Poor asthma control predicts poor quality of life and future risk of asthma exacerbation.2 Less than 25% of
patients have good control of their asthma.3
Severity of asthma is now defined by the type and intensity of treatment needed to achieve good asthma
control, not by the severity of acute exacerbations or flare-ups.4
Asthma control encompasses not only the patient’s recent clinical state (symptoms, night waking, reliever
use, and lung function), but also considers their ‘‘future risk’’. Future risk is the potential for experiencing
adverse outcomes, such as loss of control in the near or distant future, exacerbations, accelerated decline
in lung function, or treatment-related side effects.5
The following table provides criteria to assess control of asthma in adults and children over the previous 4
weeks. These are key questions for pharmacists to ask when a patient presents requesting an over-thecounter (OTC) short-acting beta-agonist (SABA) or ‘reliever’ medication (e.g. salbutamol, terbutaline). The
need to use a reliever 3 or more times a week indicates poor control and the patient should be referred to
a medical practitioner for further assessment.
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Flare-ups
In the new handbook asthma exacerbations are now referred to as flare-ups. A flare-up is defined as
worsening symptoms over hours or days, or needing reliever again within a few hours. Flare-ups are
classified as mild, moderate or severe. Flare-ups should be managed by increasing reliever use to control
symptoms.
Severity
Mild
Definition
Worsening of asthma control that is
only just outside the normal range of
variation for the individual
Moderate
Events that are (all of):
• troublesome or distressing to the
patient
• require a change in treatment
• not life-threatening
• do not require hospitalisation.
Events that require urgent action by
the patient (or carers) and health
professionals to prevent a serious
outcome such as hospitalisation or
death from asthma
Severe
Example
More symptoms than usual, needing
reliever more than usual (e.g. >3 times
within a week for a person who normally
needs their reliever less often), waking up
with asthma, asthma is interfering with
usual activities
More symptoms than usual, increasing
difficulty breathing, waking often at night
with asthma symptoms
Needing reliever again within 3 hours,
difficulty with normal activity
Table 3 - Severity classification for flare-ups
When is a preventer needed?
Regular treatment with inhaled corticosteroids is now recommended for all adults with symptoms two or
more times per month and flare-ups within previous 12 months. This is because recent evidence from
clinical trials has shown that inhaled corticosteroid-based preventers also achieve benefits for people with
‘milder’ asthma (e.g. less frequent symptoms).
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In children, preventers are now recommended for children aged 2 years and older with asthma symptoms
more than once every 6 weeks on average.
This is significant shift from the 2006 guidelines where inhaled corticosteroids were recommended for
adults and children with asthma symptoms more than three times per week or used a SABA more than
three times per week.
Potentially, most adults with asthma should be prescribed a regular low dose ICS, plus a SABA as needed:
and some children will require a low dose ICS (or montelukast or cromone) to maintain good control of
their asthma.
Stepping up
Pharmacists should play a critical role in monitoring control of asthma. Inhaler technique and adherence
should be assessed on a regular basis at every opportunity.
Prescribers are advised to check symptoms are due to asthma, what may be making asthma worse, inhaler
technique is correct, and adherence is adequate before stepping up the dose of inhaled corticosteroids or
adding a LABA.
When asthma is not controlled and inhaler technique is correct and adherence is adequate, treatment
should be stepped up until control is achieved and maintained for at least three months, at which point a
step down in treatment can be considered.
If asthma is not controlled on a low dose ICS, the next step for adults is a low dose ICS/LABA combination. A
few patients will require higher dose regular preventer (i.e. moderate-high dose ICS/LABA combination) if
good control is not achieved a low dose regular combination preventer.
Children should be stepped up to either a high dose ICS or low dose ICS plus montelukast or low dose
ICS/LABA combination product. The preferred treatment in children aged 5 years and younger is adding
montelukast rather than adding a LABA or increasing the dose of inhaled corticosteroids. when the safety
profiles of these options are compared.
Stepping down
In adults and children, consideration should be given to stepping down treatment when asthma is stable
and well controlled for more than 3 months. Stepping down may mean reducing the dose of the ICS or
stopping the LABA if ICS dose is already low.
The aim should be to find the lowest dose of medicines that will maintain good control of symptoms and
prevent flare-ups.
Specific advice is included in this edition on how to step down preventer treatment with various treatment
regimens:
•
When stepping down, make small dose adjustments gradually (e.g. reduce inhaled corticosteroid by
25–50% at intervals of 2–3 months) by stepping down through the available doses.
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Asthma prevention
Community pharmacists also have a role in providing care on managing lifestyle factors. Preventive care in
people with asthma involves:
•
•
•
•
•
•
•
Smoking cessation
Healthy eating and nutrition
Exercise and physical activity
Weight management
Immunisation
Mental health issues
Management of comorbidities e.g. sleep apnoea, allergic rhinitis, GORD
Some of the dietary strategies in asthma management are relevant to community pharmacists. Dietary
restrictions such as low-salt diets, or avoiding dairy foods or food additives, should not be routinely
recommended as strategies for managing asthma.
The following complementary medicines are considered ineffective:
•
•
•
•
•
•
Magnesium
Selenium
Vitamin B6
Vitamin C
Probiotics
Fish oil
Some complementary medicines have caused serious allergic reactions in some patients. These include:
•
•
•
Echinacea
Bee products (pollen, propolis, royal jelly)
Garlic supplements
Overall, vitamin D supplements have not been shown to be effective for asthma management; however,
500 IU cholecalciferol for 6 months is reported to reduce flare-ups associated with infections.6
Other key changes
Other key clinical questions are addressed in the new handbook:
•
•
•
•
•
Is allergen avoidance effective in improving asthma control? Click here
Does GORD treatment/therapy improve asthma control in people with asthma (adults/children)
who have a clinical diagnosis of GORD? Click here
Does planned physical activity improve asthma outcomes compared with no planned physical
activity in children and adults with asthma? Click here
What are the effects of asthma and asthma treatment on pregnancy outcomes? Click here
Does weight loss improve asthma control in overweight/obese patients with asthma? Click here
Summary
Pharmacists play an important role in supporting patients with asthma, not only through provision of OTC
reliever medication and dispensing of prescription-only products, but also by regular assessment of device
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technique and adherence to therapy. The 2014 Australian Asthma Handbook provides a patient-centred
approach to the management of asthma in children and adults. These practical, evidence-based guidelines
will support pharmacists to deliver best-practice care.
Further information
A wide range of consumer resources are available from the National Asthma Council, including the Asthma
Buddy phone app, and Asthma Australia and various state Asthma Foundation websites. These websites as
well as the NPS MedicineWise website have videos showing device technique.
NPS online case study and quiz
NPS Medicinewise News
Asthma in Australia 2011
Australian Centre for Asthma Monitoring
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New Australian asthma guidelines
MCQs
Questions based on the above article:
Select ONE alternative that best represents the correct answer to each of the following multiple choice
questions
1. According the Australian Asthma Handbook 2014, which of the following define good asthma control?
a. Need for reliever more than twice a week, night-time symptoms more than twice per month
but not weekly
b. Need for reliever less than twice a month, night-time symptoms less than twice per month
c. Need for reliever daily, brief exacerbations
d. Need for reliever ≤ two days per week, no symptoms during night or on waking
2. According the Australian Asthma Handbook 2014, which of the following statements is correct?
a. Regular treatment with an inhaled corticosteroid is recommended for most adults with asthma
b. Regular treatment with combination inhaled corticosteroid/long-acting beta2-agonist is
recommended for most adults with asthma
c. Regular treatment with an inhaled corticosteroid is recommended for most children with
asthma
d. Regular treatment with combination inhaled corticosteroid/long-acting beta2-agonist is
recommended for most children with asthma
3. A 40 year old female with poor asthma control is currently on regular fluticasone accuhaler 250mcg
twice daily. According to the new Australian Asthma Handbook, what is the next step recommended to
control her asthma?
a. No change to therapy
b. Increase fluticasone to 500mcg twice daily
c. Change to ICS/LABA combination (low dose)
d. Change to ICS/LABA combination (high dose)
4. A 10 year old child was commenced on fluticasone 100 mcg/salmeterol 50 mcg 1 inhalation twice daily
more than 6 months ago. The child runs and plays without symptoms and has no coughing during sleep.
She uses a short-acting beta2 agonist before exercise 3 to 4 times a week. What is the next step in the
management of her asthma?
a. No change to therapy
b. Add montelukast to her current therapy
c. Step up to fluticasone 250 mcg/salmeterol 50 mcg
d. Step down to fluticasone 100 mcg
5. Which of the following supplements is supported in the Australian Asthma Handbook 2014?
a. Omega-3 fatty acids
b. Echinacea
c. Vitamin D
d. Probiotics
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References
National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. National Asthma Council
Australia, Melbourne, 2014. Available from: http://www.asthmahandbook.org.au
2
Sims EJ, Price D, Haughney J, Ryan D, Thomas M. Current Control and Future Risk in Asthma Management.
Allergy Asthma Immunol Res. 2011;3(4):217-25.
3
Australian Centre for Asthma Monitoring 2011. Asthma in Australia 2011. AIHW Asthma Series no. 4. Cat.
no. ACM 22. Canberra: AIHW.
4
Reddel HK, et al. An official American Thoracic Society/European Respiratory Society statement: asthma
control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J
Respir Crit Care Med. 2009;180(1):59-99.
5
Pedersen S. From asthma severity to control: a shift in clinical practice. Prim Care Respir J. 2010;19(1):3-9.
6
Paul G, Brehm JM, Alcorn JF et al. Vitamin D and asthma. Am J Respir Crit Care Med 2012; 185: 124-32.
Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3297088/
1
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