More than 1200 practitioners (virtually) attended the official launch of the much anticipated guidelines.
The first day of spring marked not only the start of National Asthma Week but also the official launch of the Australian Asthma Handbook v2.1.
It has undoubtedly been a mammoth task, an undertaking that needs to be applauded given the vast amount of evidence that required review, interpretation, discussion and application to our local clinical context and treatment landscape, not to mention the challenge of COVID-19 thrown in for good measure. Following the teaser of the preview of the “selecting and adjusting medication for adults and adolescents” figure released in June, it was perhaps of no surprise there was a strong appetite for the release of the full guidelines and to hear from the experts that were involved in their development.
Indeed, the webinar organised by the National Asthma Council Australia garnered considerable interest with almost 1220 primary care practitioners participating or viewing the launch event. Focusing on the management of asthma in adolescents and adults, the objective of the webinar was to provide clarity on the new treatment recommendations, the evidence underlying these changes and the implications of the changes for practice and patients. The Q&A session provided the perfect opportunity for the audience and the experts to address multiple questions on new and existing recommendations. It is anticipated that such questions will help inform education initiatives to further support implementation of the revised asthma guidelines.
NAC chair Dr Joanna Wriedt said: “The Australian Asthma Handbook is a product of the hard work and long-standing commitment of the multidisciplinary Guidelines Committee, expert working groups, and the ongoing consultations with primary care health professionals throughout the country.”
Asthma management requires an individualised adjusted treatment approach
Aims:
- Maintain symptom control
- Reduce flare-up risk
- Minimise medication side effects
Representing the key component of the handbook, the treatment figure outlines five levels of asthma treatment. Selection and adjustment of treatment is guided by an individual’s symptom frequency or symptom control while taking their current treatment plus future risk of an asthma flare-up or attack. An indicative proportion of patients appropriate for treatment at each level is also provided.
WHAT ARE THE NEW TREATMENT RECOMMENDATIONS?
For mild asthma
Level 2 treatment: now two options: as-needed low-dose budesonide-formoterol (12 years and above) OR low-dose inhaled corticosteroid plus short-acting beta2-agonist reliever (any age; please refer to AAH v2.1 for specific recommendations)
Low dose budesonide-formoterol, taken whenever patients experience asthma symptoms, is a new treatment option that is an alternative to regular daily low-dose inhaled corticosteroid (ICS) plus as-needed short-acting beta agonists (SABA). Budesonide-formoterol relieves asthma symptoms and bronchoconstriction as quickly as a SABA. Low-dose ICS-containing treatment is important to reduce risk of asthma flare-ups.
Level 2 treatment is appropriate for most adults and adolescents with asthma apart from those initially presenting with frequent or uncontrolled symptoms. Very few patients should be managing their asthma with just an as-needed SABA alone – only those with symptoms less than twice a month and no risk factors for flare-ups.
For moderate-severe asthma
Level 3 and 4: Beclometasone and formoterol (18 years and above)
An additional ICS-formoterol option, which can be used as a low-dose maintenance-and-reliever therapy (MART) or as an ICS/LABA daily maintenance treatment with a SABA as-needed.
Level 3 treatment (a low-dose ICS/LABA regimen) is appropriate for some patients while Level 4 (medium-high dose ICS) should only be required by few patients with asthma. Budesonide-formoterol and beclometasone-formoterol are the only ICS-LABA combinations that can be used as relievers. Beclometasone-formoterol has been approved for subsidy by PBS for maintenance therapy (awaiting listing) but not yet for MART.
For severe asthma
Level 5: Dupilumab (12 years and above with severe ‘type 2’ asthma; a new injectable add-on therapy)
An anti-interleukin 4 receptor monoclonal antibody, this biological agent is used as an add-on therapy to an ICS/LABA for the treatment of severe type 2 asthma (elevated eosinophils and/or elevated FeNO). At present, dupilumab is not subsidised by the PBS. The other three monoclonal antibody therapies are subsidised by PBS only when prescribed by specialists (respiratory physician, clinical immunologist, allergist or general physician or paediatrician experienced in severe asthma management) for patients attending a public or private hospital, and when patients meet certain general and product-specific criteria.
After treatment is initiated by a specialist, ongoing maintenance doses can be administered in primary care or by the patient (where appropriate) but regular review for continuing PBS-funded treatment must be carried out by the specialist.
Detailed information on the indications, eligibility and reimbursement status for all these medications, can be found in the individual product labels and PBS schedules.
In another treatment update
Level 2: A lower strength fluticasone furoate (50 microgram) is now available for use in patients ?5 years of age. It is also suitable for tapering ICS dose in adults and adolescents.
Note: despite fluticasone furoate being available as a dry power inhaler, when using a metered dose inhaler, children should use a spacer device.
WHAT ARE SOME IMPORTANT REMINDERS?
Regular asthma review remains central to asthma management. As asthma can vary over time it is important to adjust treatment to maintain good symptom control and minimise risk of an asthma flare-ups at the lowest effective dose of medication.
In the words of guidelines committee chair Professor Amanda Barnard: “The basics of asthma management are still crucial.”
Key practice principles are to:
- Confirm asthma diagnosis
- Engage and involve patients to take ownership of their asthma care
- Prescribe ICS for most adults and adolescents
- Avoid over-use of SABA
- Review and adjust treatment periodically – don’t ‘set and forget’
- Check inhaler technique and adherence at each visit
- Complete a written asthma action plan for every patient
The Australian Asthma Handbook is available from: http://www.asthmahandbook.org.au
For detailed information about the new treatment recommendations and their underlying evidence, view the summary in the handbook here.
SUPPORTING THE ASTHMA COMMUNITY: BEYOND THE GUIDELINES
As well as providing the Australian Asthma Handbook, the National Asthma Council Australia offers education and resource tools to support healthcare professionals. This includes:
- A series of free accredited education workshops, which have been adapted into webinars and can be organised via your Primary Health Network or other host organisations
- A repository of Written Asthma Action Plans, available for download from the Asthma Action Plan Library
- ‘How to Use’ videos to help with correct inhaler technique and nasal sprays and irrigation, as well as more general videos relevant to asthma management
- Spirometry Handbook for Primary Care and other spirometry resources
- Information papers including white papers, asthma reports and clinical guides
For more information, visit https://www.nationalasthma.org.au.
Dr Beejal Vyas-Price (PhD) is the editor of Allergy & Respiratory Republic.
