Asthma Management Handbook

Prescribing inhaled corticosteroid-based preventers for adults

Recommendations

Prescribe a regular inhaled corticosteroid for all adults and adolescents who report any of the following:

  • asthma symptoms twice or more during the past month
  • waking due to asthma symptoms once or more during the past month
  • an asthma flare-up in the previous 12 months.
  • For all inhalers: Train the patient how to use their inhaler correctly. A physical demonstration is essential.
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):

  • Sin et al. 20041
  • Global Initiative for Asthma, 20122
  • Adams et al. 19993
  • Adams et al. 20054
  • Busse et al. 20085
  • Adams et al. 20086
  • Reddel et al. 20087
  • Boulet et al. 20098
  • O'Byrne et al. 20019
  • O'Byrne et al. 200910
  • Pauwels et al. 200311
  • Suissa et al. 200212
  • Suissa et al. 200013

When starting regular inhaled corticosteroids, begin at a low dose and review response 6–8 weeks later. (Also review during this interval, if appropriate.)

Follow the steps for conducting a treatment trial.

Table. Steps for conducting a treatment trial

  1. Document baseline lung function.
  2. Document baseline asthma control using a validated standardised tool such as the Asthma Score.
  3. Discuss treatment goals and potential adverse effects with the person.
  4. Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).
  5. At an agreed interval, measure asthma control and lung function again and document any adverse effects.
  6. If asthma control has not improved despite correct inhaler technique and good adherence, resume previous treatment and consider referral for specialist consultation.

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Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (mcg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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How this recommendation was developed

Consensus

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

Explain potential adverse effects of inhaled corticosteroids to patients.

Ask patients about any concerns they have about adverse effects and correct erroneous beliefs.

How this recommendation was developed

Consensus

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

For those taking inhaled corticosteroids via a manually-actuated pressurised metered-dose inhaler, advise them to use a valved spacer.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • National Asthma Council Australia, 200814

Advise all patients using inhaled corticosteroids to rinse their mouth with water and spit after each dose, if possible.

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):

  • National Asthma Council Australia, 200814
  • Rachelefsky et al. 200715
  • Yokoyama et al. 200716

Advise patients not to increase the dose of any preventer treatment without discussing first (except as instructed in their written asthma action plan).

How this recommendation was developed

Consensus

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

Long-acting beta2 agonists should only be used when an inhaled corticosteroid is taken concurrently – never as monotherapy for asthma.

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):

  • Ducharme et al. 201117
  • Walters et al. 200718
  • Chowdhury and Dal Pan G, 201019
  • Chowdhury et al. 201120

Where possible, avoid prescribing long-acting beta2 agonists in single-agent inhalers separate from inhaled corticosteroids, to prevent patients using a long-acting beta2 agonist alone.

Note: Occasionally patients may need to use separate devices, e.g. if the person needs an inhaled corticosteroid that is not available in combination with long-acting beta2 agonist (ciclesonide or beclometasone dipropionate). In this case, clearly instruct patients not to take long-acting beta2 agonist alone and explain the risks.

How this recommendation was developed

Consensus

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

For adults prescribed low-dose ICS for an indefinite period, explain that:

  • the main purpose of long-term low-dose ICS-based preventer is to reduce the risk of flare-ups, even if day-to-day symptoms are infrequent
  • even if the person has not experienced asthma symptoms for some time, they should not stop taking their preventer without discussing first.

Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (mcg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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How this recommendation was developed

Consensus

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

More information

Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.21

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

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Inhaled corticosteroids for adults: overview

Inhaled corticosteroid preventer medicines available in Australia

The following inhaled corticosteroids are registered by the TGA:

  • beclometasone dipropionate (low to high doses available)
  • budesonide (low to high doses available, including in combination with a long-acting beta2 agonist)
  • ciclesonide (low to high doses available)
  • fluticasone furoate (medium to high doses available, including in combination with a long-acting beta2 agonist)
  • fluticasone propionate (low to high doses available, including in combination with a long-acting beta2 agonist)

Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (mcg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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Clinical benefits

Inhaled corticosteroids are the most effective preventer medicines for adults.1, 2, 22

Inhaled corticosteroids are effective in reducing asthma symptoms, improving quality of life, improving lung function, decreasing airway hyperresponsiveness, controlling airway inflammation, reducing the frequency and severity of asthma flare-ups, and reducing the risk of death due to asthma.1234,  5, 9, 1011, 121323

Most adults with asthma benefit from regular inhaled corticosteroid treatment

The current recommendation to initiate inhaled corticosteroid treatment for adults with asthma symptoms twice or more during the past month, or who experience waking due to asthma symptoms once or more during the past month, is based on consideration of clinical trial evidence that even patients with infrequent symptoms benefit from regular use of inhaled corticosteroids:

  • In patients with recent-onset (diagnosis within 2 years) mild asthma (45% with symptoms 2 days/week or less), low-dose inhaled corticosteroid (budesonide 400 mcg/day) reduced the risk of severe flare-ups, increased symptom-free days and lung function, and protected against long-term decline in lung function associated with severe asthma flare-ups (evidence from a 5-year large randomised clinical trial). 5, 10, 11
  • In small clinical trials in adults with symptoms or reliever use twice per week or less, the use of regular inhaled corticosteroids (fluticasone propionate 250 mcg/day) improved lung function,7 reduced airway hyperresponsiveness and inflammation,78 and reduced the risk of mild flare-ups.7, 8

The current recommendation replaces the previous higher threshold for inhaled corticosteroid treatment (asthma symptoms three times a week or more, or waking at least one night per week with asthma symptoms), which was based on consensus.

Clinical benefits are achieved with low doses

Low doses of inhaled corticosteroids are sufficient to achieve benefits in most patients:

  • Regular use of low-dose inhaled corticosteroids reduced the risk of hospitalisation for acute asthma and death due to asthma (evidence from a large population cohort study).12 In that study, breaks in the use of inhaled corticosteroid of up to 3 months were associated with increased risk of death.13
  • In adults and adolescents with mild asthma who were not taking inhaled corticosteroids, starting low-dose inhaled corticosteroid (budesonide 200 mcg/day) reduced the risk of asthma flare-ups severe enough to require oral corticosteroids, and improved symptom control (evidence from a large clinical trial).9
  • In patients with recent-onset (diagnosis within 2 years) mild asthma (45% with symptoms 2 days/week or less), low-dose inhaled corticosteroid (budesonide 400 mcg/day) reduced the risk of severe flare-ups, increased symptom-free days and lung function, and protected against long-term decline in lung function associated with severe asthma flare-ups (evidence from a 5-year large randomised clinical trial). 5, 10, 11

Note: PBS status as at October 2016: Fluticasone furoate is not subsidised by the PBS, except in combination with vilanterol.

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Inhaled corticosteroids for adults: doses

Most of the benefit of inhaled corticosteroid is achieved with doses at the upper limit of the low-dose range (i.e. equivalent to 400 mcg budesonide per day,2425 200 mcg HFA beclometasone, 160 mcg ciclesonide or 200 mcg fluticasone propionate).

On average, higher doses provide relatively little extra benefit, but are associated with a higher risk of adverse effects.2 However, a small proportion of individuals may need a higher dose to achieve asthma control.2, 24, 25

The recommendation to start inhaled corticosteroid at low dose is based on the following evidence.

A meta-analysis of results from randomised controlled trials comparing different doses of inhaled corticosteroids showed:

  • An effective starting dose is 200–400 mcg/day for fluticasone propionate, 400–800 mcg/day for budesonide, or 200–400 mcg/day beclometasone.26
  • A starting dose higher than 800 mcg/day budesonide, 400 mcg/day fluticasone propionate, or 400 mcg beclometasone does not provide enough clinical benefit over lower doses to warrant routinely starting with high doses.26
  • Starting with a moderate dose of inhaled corticosteroid is as effective as commencing with a high dose and down-titrating.26 Although it may be reasonable to use a high starting dose then reduce the dose, down-titration cannot be ensured in practice (e.g. if the person does not return for planned review).
  • High doses of inhaled corticosteroids may be more effective than a moderate or low dose for controlling airway hyperresponsiveness,26 but this may not equate to a clinical benefit.

Meta-analyses627 of inhaled corticosteroid safety have shown that the risk of local adverse effects (e.g. hoarseness, oral candidiasis) and the risk of systemic adverse effects (e.g. changes in hypothalamic-pituitary-adrenal function) increase significantly at higher doses. The risk of adrenal suppression should be considered whenever high doses are used (particularly of more potent inhaled corticosteroids), or when the patient uses concomitant medicines that inhibit cytochrome P450 (e.g. ritonavir, erythromycin or ketoconazole).

Notes 

Dose equivalent for beclometasone applies to Qvar CFC-free formulation. Other brands may differ.

Do not use beclometasone dose recommendations from outdated or overseas guidelines based on older formulations containing CFC propellant – doses are different.

Table. Definitions of ICS dose levels in adults

Inhaled corticosteroid Daily dose (mcg)
Low Medium High
Beclometasone dipropionate † 100–200 250–400 >400
Budesonide 200–400 500–800 >800
Ciclesonide 80–160 240–320 >320
Fluticasone furoate* 100 200
Fluticasone propionate 100–200 250–500 >500

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate).

*Fluticasone furoate is not available as a low dose. TGA-registered formulations of fluticasone furoate contain a medium or high dose of fluticasone furoate and should only be prescribed as one inhalation once daily.

Note: The potency of generic formulations may differ from that of original formulations. Check TGA-approved product information for details.

Sources

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/

GlaxoSmithKline Australia Pty Ltd. Product Information: Arnuity (fluticasone furoate) Ellipta. Therapeutic Goods Administration, Canberra, 2016. Available from: https://www.ebs.tga.gov.au/

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Inhaled corticosteroids for adults: adverse effects

Local adverse effects

Hoarseness (dysphonia) and candidiasis are the most common local adverse effects of inhaled corticosteroids with both pressurised metered-dose inhalers and dry-powder inhalers:15

  • The rate of of dysphonia among patients taking inhaled corticosteroids has been estimated at 5–20%.28 However, higher rates of up to 58% have been reported in some studies.29 The risk varies with the device used.
  • The rate of oropharyngeal candidiasis among adults using inhaled corticosteroids has been estimated at 5–7%, with positive mouth culture for Candida albicans in approximately 25% of patients. However, higher rates of up to 70% have been reported in some studies. The risk depends on the formulation, dose and dose frequency.28

When taking inhaled corticosteroids via pressurised metered-dose inhalers, the use of a spacer reduces the risk of dysphonia and candidiasis.14 Spacers improve delivery of the medicine to the airways.

Rinsing the mouth with water after inhaling reduces the risk of oropharyngeal candidiasis.14 Quick mouth rinsing immediately after inhaling effectively removes a high proportion of remaining medicine.16

The incidence of dysphonia and candidiasis is significantly lower with ciclesonide than with equivalent doses of fluticasone propionate.30 This may an important consideration for patients who experience dysphonia, particularly for those for whom voice quality is important (e.g. singers, actors, teachers). With ciclesonide, the rate of adverse effects may not differ when taken with or without a spacer.31

Systemic adverse effects

Cross-sectional population studies have reported lower bone mineral density with long-term use of high doses of inhaled corticosteroid,32 but the effect on fracture risk in patients with asthma is unclear.

A meta-analysis of randomised controlled trials in adults older than 40 years with COPD (in which osteoporosis is more common) or asthma found no association between the use of inhaled corticosteroid and fracture risk overall, but found a slight increase in facture risk among those using high doses.33

Cross-sectional studies show a dose–response relationship between inhaled corticosteroid use for asthma or COPD, and risk of cataracts in adults.34

Long-term inhaled corticosteroid use for asthma or COPD is associated with a small increase in the risk of developing diabetes, and in the risk of diabetes progression. These risks are greatest at higher doses (equivalent to fluticasone propionate 1000 mcg/day or higher).35

The incidence of osteoporosis, cataracts and diabetes increases with age, and these conditions are also more common in smokers and in patients with COPD. Few studies have assessed risk specifically in patients with asthma.

Patients at risk of osteoporosis should be referred for bone density screening, screened for vitamin D and/or calcium deficiency, and provided with advice about maintaining bone health.

Patient concerns about adverse effects

The prevalence of side effects that patients consider troubling increases with increasing dose of inhaled corticosteroids.36 Mid and high doses are consistently associated with a higher intensity and a higher prevalence of reported adverse effects, after controlling for other factors.36

A high proportion of people with asthma may have misunderstandings and fears about using inhaled corticosteroids,3738 such as fears about weight gain, unwanted muscle development, bone fractures, susceptibility to infections and reduction of efficacy of the medicine over time.37 Most people do not discuss their concerns about inhaled corticosteroid treatment with health professionals.37 Safety concerns are a major reason for poor adherence, particularly general concerns about corticosteroids rather than concerns about specific adverse effects.39

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Inhaled corticosteroids for adults and adolescents: particle size

Medicines with small particle size (CFC-free beclometasone [Qvar] and ciclesonide) achieve a greater proportion of medicine deposited in the lungs,40 and are potentially distributed more widely in the large, intermediate, and small airways.40 However, the clinical implications have not been established.

Randomised controlled trials comparing ciclesonide with fluticasone propionate in adults and adolescents have observed lower rates of patient-reported side-effects,41 and confirmed dysphonia and oral candidiasis,30 among patients using ciclesonide than among those using fluticasone propionate.

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Inhaled corticosteroid/long-acting beta-2 agonist combinations for adults: overview
  • To avoid the possibility of patients taking a long-acting beta2 agonist without an inhaled corticosteroid, long-acting beta2 agonists should (whenever possible) be prescribed as inhaled corticosteroid/long-acting beta2 agonist combination in a single inhaler, rather than in separate inhalers. If no combination product is available for the desired medications, carefully explain to the patient that it is very important that they continue taking the inhaled corticosteroid.

Meta-analysis of evidence from randomised controlled clinical trials shows that, for adult patients already taking an inhaled corticosteroid, concomitant treatment with an inhaled corticosteroid and a long-acting beta2 agonist:1

  • reduces the risk of flare-ups, compared with increasing the dose of corticosteroids
  • reduces the risk of flare-ups, compared with inhaled corticosteroids alone.

The studies included in this meta-analysis evaluated mainly budesonide/formoterol and fluticasone propionate/salmeterol.1

Each of the following inhaled corticosteroid/long-acting beta2 agonist combinations is available as a single inhaler:

  • budesonide/formoterol
  • fluticasone furoate/vilanterol
  • fluticasone propionate/salmeterol
  • fluticasone propionate/formoterol.

There are two types of dosing regimens for inhaled corticosteroid/long-acting beta2 agonist combination therapy:

  • maintenance-only regimens (applicable to all available combinations)
  • maintenance-and-reliever regimen (applicable only to the budesonide/formoterol combination).

Maintenance-only regimens

The fluticasone propionate/salmeterol combination and budesonide/formoterol combination appear to be equally effective when used for regular maintenance treatment, based on meta-analysis of evidence from clinical trials.42 Most of the evidence for inhaled corticosteroid/long-acting beta2 agonist combination therapy is from studies using these combinations.

Less evidence from double-blind randomised controlled clinical trials is available for the newer combinations: fluticasone furoate/vilanterol and fluticasone propionate/formoterol:

  • The fluticasone furoate/vilanterol combination is equivalent to a medium-to-high dose of inhaled corticosteroids.43 In adults and adolescents already taking inhaled corticosteroids, once-daily fluticasone furoate/vilanterol 100/25 mcg reduced the risk of severe flare-ups (requiring oral corticosteroids or hospitalisation) and improved lung function, compared with fluticasone furoate alone.44 Efficacy data for the comparison of fluticasone furoate/vilanterol with other inhaled corticosteroid/long-acting beta2 agonist combinations is not available.
  • In adults and adolescents with persistent asthma and FEV1 50–80% at baseline, fluticasone propionate/formoterol achieved improvement in FEV1 comparable to that achieved with budesonide/formoterol in a 12-week randomised double-blind clinical trial.45 Other 12-week open-label studies have reported that fluticasone propionate/formoterol was as effective as budesonide/formoterol in improving lung function in adults and adolescents with poorly controlled asthma,46 and was as effective as fluticasone propionate/salmeterol in adults.47

Long-acting beta2 agonists should not be used without inhaled corticosteroids in the management of asthma.17181920 Long-acting beta2 agonists are well tolerated when given in combination with inhaled corticosteroids.4248

Maintenance-and-reliever regimen

The low-dose budesonide/formoterol combination can be used as both maintenance and reliever. Under this regimen, the combination is used for relief of asthma symptoms (instead of using a short-acting beta2 agonist reliever), in addition to its use as regular maintenance treatment.

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Combination budesonide/formoterol maintenance-and-reliever regimen in adults and adolescents: overview of efficacy

Low-dose budesonide/formoterol combination can be used as reliever for asthma symptoms (instead of using a short-acting beta2 agonist reliever), in addition to its use as regular long-term preventer treatment.49, 50,  51,  5253, 54 The following formulations can be used in maintenance-and-reliever regimens:

  • dry-powder inhaler (Symbicort Turbuhaler) 100/6 mcg or 200/6 mcg
  • pressurised metered-dose inhaler (Symbicort Rapihaler) 50/3 mcg or 100/3 mcg.

Neither the 400/12 mcg dry-powder inhaler nor the 200/6 mcg pressurised metered-dose inhaler should be used in this way.

Overall, clinical trials show that budesonide/formoterol combination as maintenance and reliever reduces the risk of flare-ups that require oral corticosteroids, compared with other current preventer regimens and compared with a fixed higher dose of inhaled corticosteroids.55

Pooled data from five randomised controlled trials assessing budesonide/formoterol maintenance-and-reliever regimens showed that similar or better levels of asthma control were achieved with budesonide/formoterol maintenance-and-reliever compared with the conventional maintenance regimen comparators:51

  • higher-dose budesonide
  • same dose budesonide/formoterol
  • higher-dose inhaled corticosteroid/long-acting beta2 agonist (budesonide/formoterol or fluticasone propionate/salmeterol).

In randomised clinical trials in patients with a history of asthma flare-up within the previous 12 months (and therefore at greater risk of flare-up in the next 12 months), the use of formoterol/budesonide as maintenance-and-reliever regimen reduced the risk of asthma flare-ups that required treatment with oral corticosteroids, compared with the use of any of the following (plus a short-acting beta2 agonist reliever as needed):515657

  • the same combination as maintenance treatment only
  • higher-dose combination as maintenance treatment only
  • higher-dose inhaled corticosteroids.

Meta-analysis of six randomised controlled trials found that maintenance-and-reliever treatment with budesonide/formoterol reduced the risk of severe asthma flare-ups (use of oral corticosteroids for 3 days or more, hospitalisation or emergency department visits), compared with higher-dose inhaled corticosteroid alone, or in combination with a long-acting beta2 agonist.58

In open-label studies in which patients were not selected for a previous history of flare-ups, there was no overall difference in time to first flare-up between budesonide/formoterol as maintenance-and-reliever regimen and conventional maintenance regimens (including inhaled corticosteroid or inhaled corticosteroid/long-acting beta2 agonist combinations, leukotriene receptor antagonists, xanthines or any other asthma medicines) with rapid-onset beta2 agonist reliever (selected according to clinician’s choice).59 However, the inhaled corticosteroid dose was higher with conventional maintenance regimens.

Note: The fluticasone propionate/formoterol combination is approved by the Therapeutic Goods Administration only for regular maintenance therapy.

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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.6061

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,62, 63, 64, 65, 66 even among regular users.67 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.68

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.62, 69, 67, 70, 71 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.67

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.72, 73

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:68

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:68

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.68 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.74, 62, 75, 76 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.75 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).60, 73

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.72, 62, 63 

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