Prescribing other preventers for adults
Although montelukast is less effective than inhaled corticosteroids for controlling asthma in adults, it may be considered as an alternative for (either of):
- people who experience intolerable dysphonia with inhaled corticosteroids despite correct inhaler technique and use of a spacer
- people who refuse other preventer options.
Note: PBS status as at October 2016: Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special Authority is available for DVA gold card holders, or white card holders with approval for asthma treatments.
When starting regular montelukast, prescribe standard adult dose and review response 6–8 weeks later. (Also review during this interval, if appropriate.)
Follow the steps for conducting a treatment trial.
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
Although cromones are less effective than inhaled corticosteroid in controlling asthma and improving lung function, they may be considered for (any of):
- people who choose not to take inhaled corticosteroids
- people who cannot tolerate inhaled corticosteroids
- people with symptoms limited to exercise-induced bronchoconstriction.
If considering sodium cromoglycate or nedocromil, explain to patients that the medicine must be taken multiple times per day, and that the device requires daily maintenance, and explain how to do this before prescribing. (Cromones are rarely prescribed to manage asthma in adults.)
- How this recommendation was developed
Based on clinical experience and expert opinion (informed by evidence, where available).
- Montelukast for adults: efficacy
In adults and adolescents with asthma that is not controlled by low-dose inhaled corticosteroid, the addition of a leukotriene receptor antagonist is less effective than the addition of a long-acting beta2 agonist in reducing the rate of asthma flare-ups that require treatment with oral corticosteroids.1 The addition of a leukotriene receptor antagonist is also associated with lesser improvement in lung function and quality of life than the addition of a long-acting beta2 agonist.1
Montelukast taken 1 hour before exercise can be used to manage exercise-induced bronchoconstriction, but it is less effective than short-acting beta2 agonists.4
Retrospective analysis of clinical trial data suggests that some people with asthma who smoke,2 or are obese,3 may achieve better asthma control with montelukast than an inhaled corticosteroid. However, prospective studies would be needed to confirm this.
Some individuals may also achieve better asthma control with montelukast than with an inhaled corticosteroid for reasons that are unknown and cannot be predicted from currently available data.
Although montelukast was previously thought to have particular benefits for people with aspirin-intolerant asthma, this has not been consistently demonstrated in clinical trials.
Within specialised severe asthma clinics, montelukast is sometimes prescribed as add-on treatment for adults.
Note: PBS status as at October 2016: Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special Authority is available for DVA gold card holders or white card holders with approval for asthma treatments.Close
- Montelukast for adults and adolescents: psychiatric effects
Post-marketing surveillance reports led to concerns about a possible association between leukotriene receptor antagonist use and suicide risk.7 A recent case-control study reported a statistically significant association between the use of leukotriene receptor antagonists and suicide attempts in people aged 19–24 years. However, this association was no longer statistically significant after adjusting for potential confounding factors, including previous exposure to other asthma medicines and previous exposure to other medicines associated with suicide.7Close
- Cromones for adults and adolescents
Sodium cromoglycate is less effective than inhaled corticosteroids in controlling asthma and improving lung function.5
Cromolyn sodium and nedocromil sodium taken before exercise can be used to manage exercise-induced bronchoconstriction, but they are only effective in approximately 50% of patients4 and are less effective than short-acting beta2 agonists.6
Cromones have a good safety profile and tolerance does not occur when either of these medicines is taken regularly.4 Maintenance of the CFC-free device is difficult for patients because the formulation is sticky and blocks the device unless it is washed and thoroughly dried every day. Therefore, patients need two mouthpieces to use alternately.Close
- 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.8
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
- Correct use of inhaler devices
High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,11, 12, 13, 14, 15 even among regular users.16 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.17
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.11, 18, 16, 19, 20 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.16
Common errors and problems with inhaler technique
Common errors with manually actuated pressurised metered dose inhalers include:17
- 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:17
- 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.17 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.23, 11, 24, 25 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.24 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).9, 22
The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.Close
- Ducharme FM. Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma. Cochrane Database Syst Rev. 2004; Issue 1: CD003133. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003133.pub2/full
- Lazarus SC, Chinchilli VM, Rollings NJ, et al. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma. Am J Respir Crit Care Med. 2007; 175: 783-790. Available from: http://www.atsjournals.org/doi/full/10.1164/rccm.200511-1746OC
- Peters-Golden M, Swern A, Bird SS, et al. Influence of body mass index on the response to asthma controller agents. Eur Respir J. 2006; 27: 495-503. Available from: http://erj.ersjournals.com/content/27/3/495.long
- Weiler JM, Anderson SD, Randolph C, et al. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol. 2010; 105: S1-47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21167465
- Guevara JP, Ducharme F M, Keren R, et al. Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma. Cochrane Database Syst Rev. 2006; Issue 2: CD003558. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003558.pub2/full
- Spooner CH, Spooner GR, Rowe BH. Mast-cell stabilising agents to prevent exercise-induced bronchoconstriction. Cochrane Database Syst Rev. 2003; 4: CD002307. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002307/full
- Schumock GT, Stayner LT, Valuck RJ, et al. Risk of suicide attempt in asthmatic children and young adults prescribed leukotriene-modifying agents: a nested case-control study. J Allergy Clin Immunol. 2012; 130: 368-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22698520
- Wilson SR, Strub P, Buist SA, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010; 181: 566-77. Available from: http://ajrccm.atsjournals.org/content/181/6/566.full
- Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
- Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
- Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
- Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
- Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
- Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
- National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
- Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
- Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
- Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
- Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
- Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
- Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
- Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
- Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924