Asthma Management Handbook

Managing severe asthma in adults and adolescents: non-pharmacological strategies and general care

Recommendations

If the person smokes, strongly advise them quit and support them to quit.

How this recommendation was developed

Consensus

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

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Provide training, information and encouragement to help patients improve their self-management skills, including:

  • inhaler technique
  • understanding the importance of good adherence to maintenance treatments
  • self-monitoring asthma symptoms
  • understanding of asthma
  • how to use their written action plan.
How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Provide every patient with an individualised written asthma action plan and update it regularly (at least yearly, and whenever treatment is changed).

How this recommendation was developed

Consensus

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

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For patients with mucus production, consider referral to a physiotherapist or online video to learn Active Cycle of Breathing technique.

How this recommendation was developed

Consensus

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

  • Lewis et al. 20121

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Assess and manage exposure to asthma triggers at home or work (e.g. cigarette smoke, allergens, irritants, infections, moulds/dampness, indoor or outdoor air pollution).

Table. Summary of asthma triggers Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/52

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Advise patients with severe asthma to keep influenza vaccination up to date.

Note: Influenza vaccines are free of charge for people with severe asthma (defined as patients requiring frequent medical consultations or the use of multiple medications)

Vaccination reduces the risk of acquiring influenza, but may not reduce the risk or severity of asthma flare-ups during the influenza season.

For patients with allergies (e.g. egg, latex), refer to national immunisation guidelines and Australasian Society of Allergy and Clinical Immunology guidance.

There is no significant increase in asthma flare-ups following vaccination with inactivated trivalent influenza vaccine.

How this recommendation was developed

Adapted from existing guidance

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

  • Australian Technical Advisory Group on Immunisation (ATAGI)2

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Counsel adults and adolescents about maintaining a healthy lifestyle including healthy eating (e.g. eating plenty of fruit and vegetables, minimising intake of processed and take-away foods that are high in saturated fats), adequate physical activity, and achieving and maintaining a healthy weight.

How this recommendation was developed

Consensus

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

  • Wood et al. 20113
  • Wood et al. 20124
  • Adeniyi and Young. 20125

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For patients taking oral corticosteroids (maintenance treatment or frequent courses) or high-dose inhaled corticosteroids, monitor and manage potential adverse effects, including:

  • check for oral candidiasis (thrush)
  • check blood pressure and blood glucose
  • DEXA scan at baseline and repeated every 1–5 years (depending on age, sex and result)
  • regular eye examination to check for cataracts and glaucoma, arranging assessment by ophthalmologist as necessary
  • consider screening for adrenal suppression (or referring for screening)
  • provide advice about the potential need for additional corticosteroids in the case of surgery or injury.
  • Risk of reduced bone density should be managed in in patients taking oral corticosteroids (e.g. falls prevention, regular weight-bearing exercise and resistance training, adequate calcium and vitamin D intake, anti-osteoporosis treatment where indicated)

Note: bisphosphonates are recommended (and subsided by the PBS) for primary fracture prevention in:

  • patients with glucocorticoid-induced osteoporosis when the T-score is ≤–1.5

  • patients with osteopenia (T score ≤1.0) treated with ≥7.5 mg prednisolone/day (or equivalent) for 3 months or more.

How this recommendation was developed

Consensus

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

  • RACGP 20176

Last reviewed version 2.0

More information

What is severe asthma?

Definitions

Severe asthma is asthma that remains uncontrolled despite high-dose inhaled corticosteroids plus long-acting beta2 agonist (with correct inhaler technique and good adherence) or maintenance oral corticosteroids, or that requires such treatment to prevent it becoming uncontrolled.7

Severe asthma is sometimes also called ‘severe refractory asthma' or 'severe treatment-resistant asthma'. However, the introduction of monoclonal antibody therapies has demonstrated that significant improvements can be seen in asthma that was previously termed ‘refractory’.

Asthma is considered to be uncontrolled if any of the following are identified:

  • poor symptom control, e.g. during previous 4 weeks any of:
    • symptoms during night or on waking
    • limitation of activities due to asthma
    • daytime symptoms on more than 2 days per week
    • need for short-acting beta2 agonist reliever on more than 2 days per week (not including doses taken prophylactically before exercise).
  • frequent severe flare-ups (e.g. more than one flare-up requiring treatment with oral corticosteroids in the previous year)
  • serious flare-ups (e.g. hospital admission, intensive care unit admission, or mechanical ventilation in the previous year)
  • persistent airflow limitation (e.g. detected by spirometry).

Patients with severe asthma are a subgroup of those with difficult-to-treat asthma. Difficult-to-treat asthma is defined as asthma that remains uncontrolled despite treatment with a high dose of an inhaled corticosteroid combined with a long-acting beta2 agonist.

Not all patients with difficult-to-treat asthma have severe asthma. Difficult-to-treat asthma includes asthma that is uncontrolled due to suboptimal adherence, inappropriate or incorrect use of medicines, environmental triggers or comorbidities. Patients whose asthma control improves rapidly after such problems are corrected are not considered to have severe asthma.7

Prevalence

Severe asthma is uncommon. Less than 4% of adults with asthma have severe asthma.8

Description

Severe asthma appears to be a distinct disease (or group of diseases) with different pathobiology from that of milder forms of asthma. It is rare for mild asthma to progress to severe asthma.9

Severe asthma imposes a high burden of disease due to symptoms, flare-ups, medication-related adverse effects and costs.10, 11

Bronchiectasis, granulomas and other auto-immune disease processes can coexist with severe asthma.9, 12 Aspirin-exacerbated respiratory disease can present as severe asthma.

Patterns of airway inflammation vary among people with severe asthma,13 which suggests that the underlying pathophysiology varies.

Inflammatory patterns identified in adults in research studies include eosinophilic (elevated sputum eosinophil count), neutrophilic (elevated sputum neutrophil count), mixed (elevated sputum eosinophil and neutrophil counts) and paucigranulocytic (sputum eosinophil and neutrophil counts within normal range).14 However, these tests are not routinely available in practice to guide treatment.

Some patients with severe asthma show sustained eosinophilia on blood tests despite good adherence to treatment with high doses of inhaled corticosteroids9, 15

Current research aims to predict which treatments will be most effective in an individual according to the findings of a range clinical investigations (e.g. sputum cell counts, peripheral blood white cell counts, fraction of exhaled nitric oxide [FeNO]) and on other clinical features such as age of asthma onset, relationship of allergies to asthma symptoms or presence of nasal polyposis. Few studies have been conducted to identify severe asthma phenotypes among children with severe asthma.13

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Living with asthma

People’s experiences of asthma

More than three-quarters of Australians with asthma describe their general health as ‘good’ to ‘excellent’.16 However, the experience of living with asthma differs between individuals.

Experiences of asthma reported in research studies are diverse. They include:17

  • frightening physical symptoms experience as ‘panicky’, a sensation of ‘choking’, ‘breathing through a straw’, ‘suffocating’ or ‘drowning’
  • feeling judged by others (family, employers/colleagues)
  • self-judgement (e.g. believing that asthma is not a legitimate reason for absence from work)
  • fearing dependency on medications
  • fearing or experiencing side effects from medication
  • fearing unpredictability of asthma symptoms that could occur while out
  • wishing to be ‘normal’.

Living with severe asthma

Studies of adults with severe asthma have identified frequently reported needs and goals, including:18

  • achieving greater personal control over their conditions by gaining knowledge about symptoms and treatment. This included receiving more information about asthma from health professionals.
  • being able to ask questions without feeling rushed during consultations
  • being involved in making decisions about their treatment
  • striving for a normal life.

People with severe asthma report a range of problems, including:1811

  • troublesome adverse effects of oral corticosteroids (e.g. weight gain, ‘puffy face’, anxiety, irritability and depression) – these can affect social relationships and cause some people reduce or stop their use
  • feelings of panic and fear of asthma symptoms – some people avoid activities and situations due to severe asthma
  • emotional distress
  • stigma
  • restrictions on social life or ability to play with children
  • restrictions on everyday activities including chores or leisure activities
  • effects on working life, including absences or the need to change occupation or give up work
  • being misunderstood by other people, who expect the person’s asthma to be readily controlled as for milder asthma
  • a sense of lack of support from their healthcare providers, including the perception that doctors did not have time to discuss asthma.

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Effects of smoking on asthma control and medicines

Smoking reduces the probability of achieving good asthma control.19 Among adults with asthma, exposure to cigarette smoke (smoking or regular exposure to environmental tobacco smoke within the previous 12 months) has been associated with a significantly increased risk of needing acute asthma care within the next 2–3 years.20

Smoking reduces response to inhaled corticosteroids and oral corticosteroids in people with asthma.212223, 24, 25 People who smoke may need higher doses of inhaled corticosteroids to receive the same benefits (improvement in lung function and reduction in flare-ups) as non-smokers.25

Therapeutic response to montelukast appears to be unchanged by smoking.23 Therefore, montelukast may be useful in smokers with mild asthma.26, 27

Note: PBS status as at March 2019: 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.

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Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,28, 29,3030, 31 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.28, 29, 32, 33, 34, 35

Poor asthma symptom control is often due to incorrect inhaler technique.36, 37

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

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Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.38 Written asthma action plans are effective if based on symptoms39 or personal best peak expiratory flow (not on percentage predicted).38

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans4041 is available online.

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Asthma self-management for adults

Effective self-management requires:

  • adherence to the agreed treatment regimen
  • correct use of inhaler devices for asthma medicines
  • monitoring asthma control (symptoms, with addition of peak expiratory flow for some patients)
  • having an up-to-date written asthma action plan and following it when asthma worsens
  • management of triggers or avoidance (if appropriate)
  • regular medical review.

Self-monitoring of asthma

Self-monitoring by the patient, based on symptoms and/or peak expiratory flow, is an important component of effective asthma self-management.42

For most patients, a daily diary is not necessary. Patients should be trained to take note if their symptoms worsen or their reliever use increases, so they can implement their written asthma action plan and/or get medical care as appropriate.

Internet-based self-management algorithms in which patients adjust their treatment monthly on the basis of control scores have been reported to be more effective than usual care.43 In patients with partly and uncontrolled asthma, weekly self-monitoring and monthly treatment adjustment may improve asthma control.44

Asthma self-management education

Patients need careful asthma education to enable them to manage their asthma effectively.

Education in asthma self-management that involves self-monitoring (by either peak expiratory flow or symptoms), regular medical review and a written action plan improves health outcomes for adults with asthma.42 Training programs that enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.42

Information alone does not appear to improve health outcomes in adults with asthma,  although perceived symptoms may improve.45

Structured group asthma education programs are available in some regions. Contact Asthma Australia in your state or territory for information about available asthma education programs.

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Asthma self-management for adolescents

Children’s knowledge of asthma improves during adolescence.46 However, the latest available data show that less than one in five (18%) Australian adolescents has a written asthma action plan, and only 28% have discussed their asthma management plan with their GP within the previous 12 months.47

During adolescence, young people get their asthma knowledge mainly from parents.46 Adolescents whose parents were born overseas in countries with a lower asthma prevalence may have less knowledge of asthma. Chronic disease carries stigma in some communities, particularly Asian cultures. Children and adolescents from culturally and linguistically diverse communities may be expected to self-manage at a younger age and with less monitoring by parents, and so may need more support and education.

Specialised asthma nurses and asthma and respiratory educators are an invaluable resource for instruction, training and providing support for adolescents with asthma and their families.

Self-management programs

Asthma self-management education programs designed for adolescents can improve asthma-related quality of life,48495051 improve asthma knowledge,484952 improve ability to use a spacer correctly,48 improve adolescents’ confidence or belief in their ability (self-efficacy) to manage their asthma,4851 increase behaviour to prevent asthma symptoms,51 increase use of preventer medicines,51 increase use of written asthma action plans,51 reduce symptoms4851 reduce limitation of activity due to asthma,51 reduce school absences due to asthma,4851 and reduce rates of acute care visits, emergency department visits, and hospitalisations.51

However, there is not enough evidence to determine which types of self-management programs for adolescents are most effective or the most important components of programs. (Few RCTs directly compared different programs.)

Most of the asthma programs designed for adolescents have been run in schools.

Peer-led asthma programs

Several studies have shown that adolescents can be trained to teach their peers about asthma self-management and motivate them to avoid smoking.495053 Asthma self-management programs for adolescents that use peer leaders can:

  • significantly influence self-management behaviour, compared with adult-led programs53
  • achieve clinically important improvements in health-related quality of life,4950 increase adolescents’ belief in their ability (self-efficacy) to resist smoking,49 and increase asthma self-management knowledge49 (compared with adolescents at schools not involved in this type of program49 or with baseline50)
  • may be particularly beneficial for boys from low socioeconomic status background.50

The Triple A (Adolescent Asthma Action) program is a school-based peer-led adolescent asthma self-management education program developed in Australia.54

Use of technology to support self-care

Providing asthma education messages through technologies that adolescents use every day (e.g. internet, phones, interactive video)555657 may be an effective way to deliver asthma health messages, compared with traditional media or with strategies that are not tailored for adolescents.

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Active cycle of breathing technique for mucus clearance

The active cycle of breathing technique is a physiotherapy technique commonly used to promote airway clearance for people with chronic lung disease (e.g. cystic fibrosis, bronchiectasis, chronic bronchitis, COPD) who have copious airway secretions.1 It is sometimes used for people with severe asthma who also have bronchiectasis.12 It can also be used for short-term management of lower respiratory tract infections.

The technique designed to clear secretions, with the aim of reducing the frequency of infections and so preventing further airway damage and deterioration of lung function.1 It may also reduce the potential for laryngeal irritation by reducing the number of coughs required to clear sputum.

One component of the active cycle of breathing is the forced expiratory technique (huffing), which consists of one or two forced expirations or huffs, followed by relaxed breathing (termed breathing control). 1

A typical active cycle of breathing consists of breathing control, 3–4 thoracic expansion exercises, breathing control, and the forced expiratory technique.1

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Bronchial thermoplasty

The bronchial thermoplasty procedure applies heat directly to the airway walls to ablate smooth muscle within the bronchus, with the purpose of reducing the potential for constriction. It may also affect nerves and inflammatory cells in the airway.14

The procedure requires three bronchoscopy procedures.14

Bronchial thermoplasty is currently being investigated as a treatment for patients with asthma that is not well controlled with medical management, and has been reported to reduce rates of severe flare-ups and emergency department visits.58, 44, 5960, 61, 62 However, it has been evaluated in only one good-quality double-blind sham-controlled trial.60 This study showed a very large placebo effect for the primary outcome measure of quality of life, possibly due to multiple factors including frequent contact with health professionals, and high-dose treatment with oral corticosteroids during the 12-week treatment period. Long-term follow-up has been limited, with no comparison of sham- and active-treated patients.

The device used in the bronchial thermoplasty procedure has been registered in Australia since 2013. A retrospective analysis63 reported data from 20 patients with severe asthma treated in 2014 and 2015 at three university teaching hospitals in NSW, Queensland and Victoria. All patients were receiving high-dose inhaled corticosteroids, long-acting beta2 agonists and long-acting muscarinic antagonists. Half the patients were also taking maintenance oral prednisolone. After bronchial thermoplasty, short-acting reliever use and the rate of flare-ups requiring oral corticosteroids were significantly reduced. Five of 10 patients completely discontinued maintenance oral corticosteroids.63

An ongoing real-world US study64 followed patients who had undergone bronchial thermoplasty due to poor asthma symptom control despite treatment with high doses of inhaled corticosteroid and long-acting beta2 agonists. At 3 years after the procedure, substantial reductions in severe flare-ups, emergency department visits and hospitalisation due to asthma were reported, compared with baseline.64 However, baseline adherence and inhaler technique were not reported.

Potential short-term adverse effects include worsening asthma, atelectasis, and pneumonia.65 Long-term safety data are limited.14

Bronchial thermoplasty should only be considered after the patient has been evaluated at a highly specialised severe asthma clinic, and in conjunction with an interventional pulmonology multidisciplinary meeting. Adherence and inhaler technique should be assessed before considering the procedure. All patients should be included in a registry.

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Immunisation

Influenza and pneumococcal infections contribute to some acute flare-ups of asthma in people with asthma.266 People with obstructive airways disease, including asthma and COPD have a higher risk of invasive pneumococcal disease.66

Influenza vaccination reduces the risk of influenza and pneumococcal vaccination reduces the risk of pneumococcal pneumonia. However, the extent to which influenza vaccination and pneumococcal vaccination protect against asthma flare-ups due to respiratory tract infections is uncertain.6667[REFERENCE927], 68

A 2017 systematic review68 reported that no randomised controlled trials assessing the effect of vaccination on asthma flare-ups had been performed since 2001. Meta-analysis of randomised controlled trials and observational studies found that influenza vaccination protected against 59–78% of asthma flare-ups.68 However, the quality of the included studies was low and were at high or unclear risk of bias.68

The use of inactivated trivalent influenza vaccine has not been associated with an increase in the risk of asthma flare-ups.

The Australian Immunisation Handbook2 recommends annual influenza vaccination for these groups (in addition to other risk groups and health workers):

  • patients with severe asthma, defined as those who need frequent hospital visits and multiple medicines for asthma
  • all Aboriginal and Torres Strait Islander people aged 15 years and over
  • all adults ≥65 years
  • patients with COPD
  • pregnant women
  • for any adult who wishes to avoid influenza.

Influenza vaccines are free of charge for people with severe asthma (defined as patients requiring frequent medical consultations or the use of multiple medications).

Asthma, atopic dermatitis (eczema) and allergic rhinitis (hay fever) are not contraindications to any vaccine, unless the person is receiving high-dose oral steroid therapy.2 There is no significant increase in asthma flare-ups immediately after vaccination with inactivated influenza vaccination.67

To be effective, influenza vaccination must be given every year before the influenza season.

People at increased risk of invasive pneumococcal disease include:

  • people with severe asthma (defined as those who need frequent hospital visits and multiple medicines for asthma)
  • people using corticosteroid therapy equivalent to ≥2 mg/kg per day of prednisolone for more than 1 week.

For information about immunisation (including recommended dose schedules for influenza and pneumococcal vaccination, and eligibility for free vaccines), refer to the current version of the Australian Immunisation Handbook.2

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Healthy living and asthma
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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:69

  • The rate of of dysphonia among patients taking inhaled corticosteroids has been estimated at 5–20%.70 However, higher rates of up to 58% have been reported in some studies.71 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.70

When taking inhaled corticosteroids via pressurised metered-dose inhalers, the use of a spacer reduces the risk of dysphonia and candidiasis.72 Spacers improve delivery of the medicine to the airways.

Quick mouth rinsing immediately after inhaling effectively removes a high proportion of remaining medicine.73 This may reduce the risk of oropharyngeal candidiasis ('thrush').

The incidence of dysphonia and candidiasis is significantly lower with ciclesonide than with equivalent doses of fluticasone propionate.74 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.75

Systemic adverse effects

Cross-sectional population studies have reported lower bone mineral density with long-term use of high doses of inhaled corticosteroid,76 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 fracture risk among those using high doses.77

Cross-sectional studies show a dose–response relationship between inhaled corticosteroid use for asthma or COPD, and risk of cataracts in adults.78

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 microg/day or higher).79

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.80 Mid and high doses are consistently associated with a higher intensity and a higher prevalence of reported adverse effects, after controlling for other factors.80

A high proportion of people with asthma may have misunderstandings and fears about using inhaled corticosteroids,8182 such as fears about weight gain, unwanted muscle development, bone fractures, susceptibility to infections and reduction of efficacy of the medicine over time.81 Most people do not discuss their concerns about inhaled corticosteroid treatment with health professionals.81 Safety concerns are a major reason for poor adherence, particularly general concerns about corticosteroids rather than concerns about specific adverse effects.83

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References

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  2. Australian Technical Advisory Group on Immunisation (ATAGI), Department of Health and Ageing. The Australian Immunisation Handbook. 10th Edition. Department of Health and Ageing, Canberra, 2013. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
  3. Wood, L G, Garg, M L, Gibson, P G. A high-fat challenge increases airway inflammation and impairs bronchodilator recovery in asthma. J Allergy Clin Immunol. 2011; 127: 1133-1140.
  4. Wood, L G, Garg, M L, Smart, J M, et al. Manipulating antioxidant intake in asthma: a randomized controlled trial. Am J Clin Nutr. 2012; 96: 534-543.
  5. Adeniyi, F B, Young, T. Weight loss interventions for chronic asthma. Cochrane Database Syst Rev. 2012; Issue 7: . Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD009339.pub2/full
  6. The Royal Australian College of General Practitioners,, Osteoporosis Australia,. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd. RACGP, East Melbourne, 2017.
  7. Chung, K F, Wenzel, S E, Brozek, J L, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J. 2014; 43: 343-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24337046
  8. Hekking, P. P., Wener, R. R., Amelink, M., et al. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015; 135: 896-902. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25441637
  9. Wenzel, S. E., Brillhart, S., Nowack, K.. An invisible disease: severe asthma is more than just "bad asthma". Eur Respir J. 2017; 50: . Available from: http://erj.ersjournals.com/content/50/3/1701109.long
  10. Israel E, Reddel HK. Severe and difficult-to-treat asthma in adults. N Engl J Med. 2017; 377: 965-976. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28877019
  11. Foster JM, McDonald VM, Guo M, Reddel HK. "I have lost in every facet of my life": the hidden burden of severe asthma. Eur Respir J 2017; 50: Available from: https://www.ncbi.nlm.nih.gov/pubmed/28931662/
  12. Chalmers, J. D., Sethi, S.. Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults. NPJ Prim Care Respir Med. 2017; 27: 18. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28270656
  13. Papi, A., Brightling, C., Pedersen, S. E., Reddel, H. K.. Asthma. Lancet. 2018; 391: 783-800. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29273246
  14. Centre of Excellence in Severe Asthma,, Severe asthma toolkit. **, Centre of Excellence in Severe Asthma 2018. Available from: https://toolkit.severeasthma.org.au
  15. Papi, A., Ryan, D., Soriano, J. B., et al. Relationship of inhaled corticosteroid adherence to asthma exacerbations in patients with moderate-to-severe asthma. J Allergy Clin Immunol Pract. 2018; : . Available from: https://www.ncbi.nlm.nih.gov/pubmed/29627457
  16. Reddel, H. K., Sawyer, S. M., Everett, P. W., et al. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust. 2015; 202: 492-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25971575
  17. Pickles, K., Eassey, D., Reddel, H. K., et al. "This illness diminishes me. What it does is like theft": A qualitative meta-synthesis of people's experiences of living with asthma. Health Expect. 2018; 21: 23-40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/28768067/
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