Asthma Management Handbook

Managing work-related asthma

Recommendations

Manage work-related asthma as for other asthma, using a stepped approach to medication and adjusting to maintain good control at the lowest effective dose, with an emphasis on avoiding exposure to workplace triggers.

Table. Guide to selecting and adjusting asthma medication for adults and older adolescents

Clinical situation

Action

Newly diagnosed asthma

Consider low-dose ICS (plus SABA as needed)

If symptoms severe at initial presentation, consider one of:

  • ICS plus a short course of oral corticosteroids
  • a short initial period of high-dose ICS then step down
  • (private prescription) combination ICS/LABA

See: Table. Initial treatment choices (adults and adolescents not already using a preventer) 

Good recent asthma symptom control

If maintained 2–3 months, no flare-up in previous 12 months and low risk for flare-ups, step down where possible (unless already on low-dose ICS)

Partial recent asthma symptom control

Review inhaler technique and adherence – correct if suboptimal

If no improvement, consider increasing treatment by one step and reviewing (if still no improvement, return to previous step, review diagnosis and consider referral)

Poor recent asthma symptom control

Review inhaler technique and adherence – correct if suboptimal

Confirm that symptoms are likely to be due to asthma

Consider increasing treatment until good asthma control is achieved, then step down again when possible

Difficult-to-treat
asthma ‡

Consider referral for assessment or add-on options

Patient with risk
factors §
 

Tailor treatment to reduce individual risk factors

† PBS status as at October 2016: ICS/LABA combination therapy as first-line preventer treatment is not subsidised by the PBS, except for patients with frequent symptoms while taking oral corticosteroids.

‡ Poor recent asthma symptom control despite ICS/LABA combination at high–medium dose with good adherence and inhaler technique.

§ Risk factors for asthma events or adverse treatment effects, irrespective of level of recent asthma symptom control.

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Figure. Stepped approach to adjusting asthma medication in adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/31

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Aasen et al. 20131
  • Baur et al. 20122
  • Dykewics, 20093
  • Heederik et al. 20124
  • Henneberger et al. 20115
  • Hoy R et al. 20096
  • Tarlo et al. 20087
  • Vandenplas et al. 20118

Advise people with work-exacerbated asthma or irritant-induced occupational asthma that they may be able to control their asthma while continuing their job, provided that their employer undertakes effective measures to minimise their exposure to triggers in the workplace.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Aasen et al. 20131
  • Baur et al. 20122
  • Dykewics, 20093
  • Heederik et al. 20124
  • Henneberger et al. 20115
  • Hoy et al. 20106
  • Tarlo et al. 20087
  • Vandenplas et al. 20118

Advise people with confirmed sensitiser-induced occupational asthma that:

  • the prognosis is best if they completely avoid exposure, beginning early after developing symptoms
  • their asthma may not improve unless they can completely avoid exposure.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Aasen et al. 20131
  • Baur et al. 20122
  • Dykewics, 20093
  • Heederik et al. 20124
  • Henneberger et al. 20115
  • Hoy et al. 20106
  • Tarlo et al. 20087
  • Vandenplas et al. 20118

For patients with occupational asthma, offer referral to a specialist (e.g. respiratory physician, occupational physician or allergist) with experience in investigating and managing work-related asthma, if possible.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For any patient who is considering leaving their job due to asthma symptoms, offer referral to a specialist (e.g. respiratory physician, occupational physician or allergist) with experience in investigating and managing work-related asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Referral options for investigation of work-related asthma

To identify a specialist with experience investigating work-related asthma, consult the Thoracic Society of Australia and New Zealand or the Australasian Faculty of Occupational and Environmental Medicine.

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Advice for patients about work-related asthma

Choice of occupation or workplace

There is insufficient evidence to determine whether people with asthma or allergies should avoid certain jobs to avoid developing work-related asthma.

People with existing asthma or atopy might consider avoiding workplaces where employers cannot prevent exposure to known sensitisers or irritants.5 They should be made aware of risks when considering employment at such workplaces.

Patients with work-exacerbated asthma or irritant-induced occupational asthma

Unless asthma is severe, patients with work-exacerbated asthma or irritant-induced occupational asthma can usually remain in their job if exposure to workplace triggers and respiratory irritants can be minimised (e.g. by changing tasks, improving ventilation or work processes, or use of a face mask and respirator to avoid short-term exposure).6

Patients with sensitiser-induced occupational asthma

For sensitiser-induced occupational asthma, optimal management involves completely avoiding exposure as soon as possible.6 Compared with complete avoidance, reduced exposure to sensitisers is associated with a higher risk of failure to improve, worsening symptoms and nonspecific bronchial hyperresponsiveness.8 Patients should be offered assessment by a specialist in occupational asthma before giving up their job.

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References

  1. Aasen TB, Burge PS, Henneberger PK, et al. Diagnostic approach in cases with suspected work-related asthma. J Occup Med Toxicol. 2013; 8: 17. Available from: http://www.occup-med.com/content/8/1/17
  2. Baur X, Sigsgaard T, Aasen TB, et al. Guidelines for the management of work-related asthma. Eur Respir J Supplement. 2012; 39: 529-45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22379148
  3. Dykewics MS. Occupational asthma: Current concepts in pathogenesis, diagnosis, and management. J Allergy Clin Immunol. 2009; 123: 519-528. Available from: http://www.jacionline.org/article/S0091-6749(09)00214-0/fulltext
  4. Heederik D, Henneberger PK, Redlich CA. Primary prevention: exposure reduction, skin exposure and respiratory protection. Eur Respir J. 2012; 21: 112-124. Available from: http://err.ersjournals.com/content/21/124/112.full
  5. Henneberger PK, Redlich CA, Callahan DB, et al. An official american thoracic society statement: work-exacerbated asthma. Am J Respir Crit Care Med. 2011; 184: 368-78. Available from: http://ajrccm.atsjournals.org/content/184/3/368.long
  6. Hoy RF, Abramson MJ, Sim MR. Work related asthma - diagnosis and management. Aust Fam Physician. 2010; 39: 39-42. Available from: http://www.racgp.org.au/afp/201001/35841
  7. Tarlo SM, Balmes J, Balkissoon R, et al. Diagnosis and management of work-related asthma: American College Of Chest Physicians Consensus Statement. Chest. 2008; 134(3 Suppl): 1S-41S. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1044851
  8. Vandenplas O, Dressel H, Wilken D, et al. Management of occupational asthma: cessation or reduction of exposure? A systematic review of available evidence. Eur Respir J. 2011; 38: 804-11. Available from: http://erj.ersjournals.com/content/38/4/804.full