Peer group discussion: The pharmacological management of asthma in adolescents and adults has changed

Published: 4 August 2020

It is strongly recommended that the linked article is read before considering the questions.

• The pharmacological management of asthma in adolescents and adults has changed

The recently released New Zealand adolescent and adult asthma guidelines contain a new stepwise treatment pathway that recommends one of the biggest changes in asthma management in decades. Many prescribers will need to review their practice in response to the new recommendations; this is an opportunity to reset how asthma is managed and to improve health outcomes for patients.

For more than 50 years, people with asthma have been prescribed a short-acting beta₂-agonist (SABA) as the first-line treatment for symptom relief. The new Asthma and Respiratory Foundation NZ guidelines (2020) reflect the shift in the evidence which now favours budesonide/formoterol over SABAs for the relief of asthma symptoms. This change has resulted in the term “anti-inflammatory reliever” (AIR) therapy to describe treatment with a sole inhaler combination of the inhaled corticosteroid (ICS) budesonide and the fast-onset, long-acting beta₂-agonist (LABA) formoterol. A single combination inhaler is the preferred choice for both symptom relief and maintenance but an ICS (or ICS/LABA) with as needed SABA is an alternative for patients not switched to AIR. The budesonide/formoterol 200/6 (or 100/6) Turbuhaler dry powder inhaler (DPI) can be used both for maintenance treatment and for relief of symptoms as needed, i.e. only one inhaler is required. The Vannair metered dose inhalers (MDI – 200/6 and 100/6) may, however, be preferred by patients who find the Turbuhaler difficult to manipulate; prescribing this inhaler as an unapproved indication may be reasonable if it is likely to result in improved adherence.

All adolescents^* and adults with asthma, including those with exercise-induced or infrequent symptoms, should now use an ICS-containing inhaler to control their symptoms and reduce their risk of exacerbations. This provides consistent messaging to patients and prevents them developing a reliance on a SABA that can be difficult to overcome later. While many primary care clinicians have been recommending early ICS initiation for years, this new recommendation will provide clarity in the management of patients with infrequent or exercise-associated symptoms as well as aiding adherence in those who were not regularly taking ICS treatment.

^* Defined as people aged 12–17 years

Asthma should still be managed in a stepwise manner and treatment stepped up or down in order to determine the optimal level that controls symptoms, manages exacerbation risk and minimises adverse effects. The level of treatment required to achieve control is in turn used to define asthma severity, e.g. mild asthma is well-controlled at the first step of treatment and severe asthma is uncontrolled despite maximal treatment taken correctly.

Asthma is highly prevalent in New Zealand with 11.5% of people aged over 15 years diagnosed and receiving treatment to control their symptoms. Māori and Pacific peoples and those living in deprived areas are more likely to have asthma and more likely to be severely affected by it. Inequities in asthma care need to be addressed. Institutional racism is one potential reason for these inequities. Māori are less likely than New Zealand Europeans to be prescribed an ICS, to have an asthma action plan or to receive appropriate asthma education. AIR therapy with budesonide/formoterol, either alone or as maintenance and reliever treatment, i.e. SMART, has been shown to improve asthma control in Māori patients. Pacific peoples and people with disadvantaged backgrounds also experience inequities and a significant burden of respiratory disease; similar considerations are required to improve health outcomes for these groups.

Questions to consider:

1. The long-term management of asthma using just a SABA for as-required symptom relief is no longer recommended. This means that most primary care clinicians will have several patients who should be reviewed and their treatment changed to AIR therapy. What is your strategy for reviewing a patient's asthma regimen? For example, will you recall all patients, or will you change their medicines when the next opportunity arises? Will you prioritise any particular patient groups for review? Has the impact of COVID-19 and the lockdown affected your capacity as a practice to make changes such as this?
2. The new guidelines reflect a shift in the accumulated weight of evidence with budesonide/formoterol now preferred over SABAs. Many patients will need to change their inhaler type (from an MDI to a DPI) based on this recommendation. Do you feel patients will be receptive to these changes, particularly if they are heavily reliant on their SABA (either from poor control or habitual use of a SABA)? What strategies could be put in place to help patients understand how and why their inhalers need to change?
3. The new guidelines apply to adults and adolescents aged 12-17 years. Adolescence is often a time of change – asthma may improve or worsen, risk-taking behaviours may increase, e.g. smoking, adherence may decrease. Thinking about the adolescents in your practice population, what additional strategies or resources do you feel may be needed to help these patients understand and adapt to the changes? Do you utilise other members of your primary care team e.g. practice nurses, to do this? Are you aware of, or use, any other specialist asthma education services in your area?
4. Do you usually prepare an asthma action plan with patients? If not, why not? Do you think patients benefit from an action plan? Are you aware that the Asthma Foundation has templates on their website specifically for SMART therapy and plans written in te reo Māori and Samoan?
5. Inhaler technique can have a significant impact on the degree of control of asthma. Do you routinely assess inhaler technique with patients? Do you find time to do this or is it a task that can be delegated to other members of the primary care team, e.g. practice nurses or pharmacists? In your experience, how do you think patients will manage with the Turbuhaler device?
6. Do you have any patients with severe or brittle asthma in your practice? Before reading the asthma article were you aware of the add-on treatments that are available and recommended for these patients with poorly controlled asthma? There are two biological medicines now funded with Special Authority approval on application from a respiratory physician or clinical immunologist. Are there any patients in your practice who might now qualify for, and benefit from, this type of treatment?