Breathing easy: new ways to manage asthma
Navigating newer treatments and medications for asthma are key to helping the millions of Australians living with the sometimes-fatal condition breathe easier.
Being able to breathe well is something we can easily take for granted, but for the 2.7 million Australians living with asthma, the struggle for breath can be not only debilitating but also life threatening.
Dr Brett Montgomery
Even though emergency department presentations for asthma are falling – in 2017-2018 there were 38,792 asthma-related hospitalisations in Australia, a drop from 70,034 the previous year – there are still more than 400 people who die from asthma complications every year in Australia, according to Asthma Australia.
“Our prevalence of asthma is higher than many other countries,” says Dr Brett Montgomery, Perth GP and member of the National Asthma Council Australia Guidelines Committee.
“Asthma deaths are generally declining, but 421 Australians died of asthma in 2019. Even if that’s a smaller number than it used to be, that’s still 421 too many deaths. We would like it to be as close to zero as possible,” he told Medical Forum.
While there is a long-term declining trend in asthma-related deaths, the 417 deaths due to asthma in 2020 isn’t a significant fall from the previous year.
A Medical Journal of Australia study published in 2015 showed that many Australians with asthma were missing out on effective treatments that could improve their asthma control.
It found that only about half of people with asthma had good control and about a quarter had very poor control over their condition. In people with uncontrolled asthma, quite a large proportion were not using regular preventer medicines.
“Sadly, I think we would find similar statistics if we were to run a similar survey today,” Dr Montgomery said.
MISSED CHANCES
“We know there are many missed opportunities in terms of asthma care. People who have not been managing their asthma in ways that we would recommend are very much overrepresented amongst people who have serious asthma outcomes.”
People living with asthma may get into the habit of reaching for their blue inhaler in the morning if symptoms are bearable enough, but Dr Montgomery thinks better asthma treatment is achievable if people work collaboratively with their doctors.
“Patients might have symptoms that they find tolerable. Maybe it doesn’t bother them much if they’re waking up every morning a bit wheezy and they’ve got into the habit of reaching for that reliever puffer. For some people, that just becomes an accepted part of their life. But health professionals know that things could be better with different treatments,” he says.
Dr Montgomery adds that patients should know that persistent symptoms of feeling wheezy or tight in the morning or overnight, frequent reliever use, or asthma interfering in their lives are all indications they are at higher risk of having a significant exacerbation of asthma which could be detrimental enough to land them in hospital or even cause death.
National Asthma Council Australia’s updated Asthma Handbook outlines optimal ways to manage the treatment of the condition at different stages, from mild to severe asthma, with the guidelines clearly stating that taking a simple short-acting beta-agonist (SABA) reliever medication alone is not enough.
“There are very few people who have mild enough asthma that we’d be comfortable for them to use just the reliever puffers they can get over the counter,” Dr Montgomery said. “Almost all adults and adolescents with asthma should be on more than just a SABA.”
It has been standard practice for many years in Australia for doctors to prescribe regular daily maintenance of inhaled corticosteroid (ICS) at a low dose plus a SABA reliever as needed.
STANDARD CARE
Dr Montgomery said that most patients should be on a low dose of an inhaled corticosteroid medicine to improve lung function and to reduce the risk of and to prevent otherwise preventable exacerbations of asthma and hospitalisations.
If this treatment was not working effectively after several weeks – and assuming the patient was taking it correctly – then a long-acting beta-agonist (LABA) lasting 12 or more hours could be incorporated into the treatment in combination with the low-dose steroid.
“ICS-LABA combinations have been around for years now and are familiar to GPs, but there have also been a lot of changes with them, which can get confusing. There are new ICS-LABA combination inhalers, but there are also new ways of using them,” he said.
The first way ICS-LABA combinations were used was simply as regular maintenance inhalers, and this is still a valid way to use them, but some ICS-LABA preparations have other uses.
Formoterol is a long-acting beta-agonist (LABA) which, unlike some other LABAs, also works to relieve symptoms immediately, which means it can be used in other ways. The first is as maintenance and reliever therapy (MART), which GPs will know has been used in Australia for about 15 years.
GET IN CONTROL
“The idea of that is you use it regularly, so you’re taking it twice a day, but on top of that you’re taking another puff from the same inhaler as you need it if you get symptoms,” Dr Montgomery explains. “This is a regime for people who haven’t got good asthma control on simpler preventers like a low-dose ICS alone.”
What is much newer, though, is the use in mild asthma of budesonide-formoterol in mild asthma simply as-needed, without a regular maintenance component. This was only approved by the PBS in 2020.
“Using this combination inhaler simply as needed may seem unusual at first because many of us would have been taught at medical school that steroids have to be taken regularly to work. I know I was sceptical initially. But there are now several big trials that looked at that strategy and found it is safe and about as effective as the traditional regular ICS plus as-needed SABA approach. That’s why they’re both seen as legitimate options now,”
he said.
Dr Montgomery likes to remind his patients about how ICS and SABA medicines differ.
“I tell them that steroids reduce swelling and mucous production and other features of airway inflammation, doing more than the SABAs, which largely just relax airway smooth muscle. But a problem is that they act more slowly than SABAs, which means some patients reject them too quickly,” he said.
“Often people need to be on inhaled corticosteroids for weeks to really see their optimal benefit. But patients are used to using their short-acting beta agonists, which work marvellously quickly.
“If ICS medicines aren’t felt to work as quickly as they expect, some people give up on them and they just stick to what gives them instant relief. That’s a shame, because they’re missing out on significant protection. One thing I try to do with patients is to set them up with the right expectations for their new medicine, so they give it a good go for a few weeks rather than rushing to judgment.”
A study published in 2020, which looked at a sample of PBS data from 2014 to 2018, suggests that more than two-thirds of people being prescribed corticosteroids were being prescribed higher doses and most of those people were using them infrequently.
“This isn’t how things should be if we were following the evidence,” Dr Montgomery said. “What we should be seeing is most people using lower doses of steroids, and most of those people using them frequently.
“Infrequent use can be appropriate in mild asthma with low-dose budesonide-formoterol but is otherwise not recommended. The pattern seen of high ICS doses and infrequent use is a concern, suggesting missed opportunities for achieving better asthma control and preventing exacerbations and hospitalisations.”
HELPFUL INFO
National Asthma Council’s new Selecting & Adjusting Asthma Medication for Adults & Adolescents visual medications reference, together with the Asthma & COPD Medications chart, illustrate the drug names according to the treatment steps.
This makes it easier for GPs to translate the recommendations into a prescription, while involving patients in the decision making. Over time, management may move up or down the steps in the chart depending on how well controlled a patient’s asthma is.
Before stepping up from one level of the pyramid to the next and prescribing a more potent or complicated treatment, Dr Montgomery says it’s important to ask the patient some questions. “Ask the simple things like, is my patient actually remembering to take their puffer and are they taking it correctly?”
Higher doses of ICS are not found until step 4 of the guidelines. Beyond this is the option of adding a long-acting muscarinic antagonist (LAMA) medication, in an ICS-LAMA-LABA combination.
“LAMAs are familiar to GPs from COPD management, of course,” says Dr Montgomery.
“But their use in asthma is quite new. They do have an evidence base in asthma, but the evidence – like the PBS criteria – is limited to people with severe asthma who are still getting exacerbations despite good use of solid doses of ICS-LABA. They are heavily promoted at present but certainly aren’t a first-line option.”
Looking at the new medications chart, Dr Montgomery said it illustrated just how many different sorts of puffers there were.
“It’s hard to keep up with all the latest devices but it’s a GP’s role – along with pharmacists and asthma educators – to help patients understand their medicines and how to use the devices they come in,” he said.
National Asthma Council has a series of how-to videos on every asthma drug available, demonstrating to both health professionals and patients how to use their devices.
Dr Montgomery sees patient understanding as a core strategy in tackling the lingering public health challenge of asthma.
“For many people, good asthma control is achievable,” he said. “For our patients who haven’t ended up in hospital yet, and whose experience of asthma may be persistent but apparently mild, it’s very easy for that to become normalised.
“It’s important to challenge that perception and explain to people why asthma control is important. It’s partly about making their day-to-day life less troubled with asthma symptoms but also about preventing those less frequent but more serious bad outcomes.”