New Australian asthma guidelines

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1 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

2 New Australian asthma guidelines The National Asthma Council 2014 Australian Asthma Handbook 1 was released in May, with important changes that every pharmacist should be aware of. The new guidelines are only available on-line at 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 beta 2 -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.

3 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 Pharmacological class Medications Relievers Short-acting beta 2 -agonist Salbutamol Terbutaline sulfate Budesonide/eformoterol fumarate dihydrate Inhaled corticosteroid/rapid-onset long-acting beta 2 -agonist combination Preventers Inhaled corticosteroid Beclomethasone dipropionate Budesonide Ciclesonide Fluticasone propionate

4 Inhaled corticosteroid/ long-acting beta 2 -agonist combinations Leukotriene receptor antagonists Cromones 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.

5 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 Definition Example Mild Worsening of asthma control that is only just outside the normal range of variation for the individual 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 Moderate Severe 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 Table 3 - Severity classification for flare-ups 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 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).

6 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.

7 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

8 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

9 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 beta 2 -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 beta 2 -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 beta 2 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

10 References 1 National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. National Asthma Council Australia, Melbourne, Available from: 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): Australian Centre for Asthma Monitoring Asthma in Australia 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): Pedersen S. From asthma severity to control: a shift in clinical practice. Prim Care Respir J. 2010;19(1): Paul G, Brehm JM, Alcorn JF et al. Vitamin D and asthma. Am J Respir Crit Care Med 2012; 185: Available from:

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