Asthma Management Handbook

Stepping down treatment in adults

Recommendations

If a patient taking moderate-dose or high-dose inhaled corticosteroid (with or without long-acting beta2 agonist) has experienced good asthma control for 2–3 months and is at low risk of flare-ups, consider stepping down by one step.

  • Do not attempt dose reduction or step down if the person is about to travel, during a respiratory infection, or when at risk of a respiratory tract infection (e.g. during the colder winter months).

Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40

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

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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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).

During pregnancy, consider stepping down only if the woman is taking an inappropriately high dose of a medicine.  

Note: Stepping down is not a priority during pregnancy because of the risk of flare-up.

How this recommendation was developed

Consensus

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

Before stepping down:

  • find out what dose and how often the person is actually taking their prescribed preventer medicines. (To elicit accurate information, ask in a non-judgemental, empathic way.)
  • document current level of asthma control and risk factors
  • make sure the patient’s written asthma action plan is up to date.

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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Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)

Good control

Partial control

Poor control

All of:

  • Daytime symptoms ≤2 days per week
  • Need for reliever ≤2 days per week
  • No limitation of activities
  • No symptoms during night or on waking

One or two of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

Three or more of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

† Not including SABA taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

Note: Recent asthma symptom control is based on symptoms over the previous 4 weeks.

Adapted from:

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org/

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Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>2 canisters per month)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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How this recommendation was developed

Consensus

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

When stepping down, make small dose adjustments gradually (e.g. reduce inhaled corticosteroid by 25–50% at intervals of 2–3 months) by stepping down through the available doses.

  • The fluticasone furoate/vilanterol combination is not available in a low dose
How this recommendation was developed

Consensus

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

If after stepping down the person experiences an overall increase in symptoms and/or decrease in lung function, they should resume their previous dose.

How this recommendation was developed

Consensus

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

For adults taking low-dose inhaled corticosteroid in combination with a long-acting betaagonist, consider either of the following options if asthma is well controlled for 2–3 months:

  • maintain this treatment long term
  • replace combination inhaler with an inhaled corticosteroid at the same dose.
  • If withdrawal of long-acting beta2 agonist leads to loss of asthma symptom control, this will usually be evident within the first few days and the person should resume combination treatment.

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), with particular reference to the following source(s):

  • Reddel et al. 20101
  • Thomas et al. 20112
  • Brozek et al. 20123

For adults with a confirmed asthma diagnosis taking low-dose inhaled corticosteroid alone, maintain treatment long term to reduce the risk of flare-ups.

  • Many patients who experience few asthma symptoms stop taking preventer treatment without discussing with their prescriber. Explain that regular low-dose inhaled corticosteroid will reduce their risk of flare-ups, even if day-to-day symptoms are infrequent.

Table. Confirming the diagnosis of asthma in a person using preventer treatment Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/9

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), with particular reference to the following source(s):

  • Rank et al. 20134

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).

For adolescents taking low-dose inhaled corticosteroid whose asthma has been well controlled for several months, consider a trial cessation of inhaled corticosteroid.

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

Stepping down regular asthma medicines in adults

The main aim of medical treatment for asthma is to achieve good asthma control and minimise the risks of asthma with the lowest effective dose of preventer medicines for each individual.

Stepping down is considered when the patient has experienced good asthma control for 2–3 months and is at low risk of flare-ups.

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

General tips

It is important to ascertain the person’s actual treatment regimen before stepping down, because many patients may already be taking their preventer only intermittently.

Those who deliberately avoid taking their preventer due to concerns about inhaled corticosteroids may accept regular daily treatment at a lower dose, with an action plan to deal with flare-ups.

Steps down should be planned before the patient has finished their current inhaler, so that the previous dose can be resumed immediately if asthma control deteriorates.

Patients should be advised to step back up if they or their clinician judge that their asthma is worse overall (not just after the first time they experience asthma symptoms after stepping down). Patients and clinicians should agree beforehand on criteria for worsening asthma control.

Some patients are very concerned about reducing their dose (despite the risk of treatment-related adverse effects) and may prefer to stay on high doses for long periods. To enable early detection of deterioration in control during step-down, patients can be asked to monitor their peak flow for 2 weeks before, and 3–4 weeks after, the dose reduction.

Stepping down inhaled corticosteroid dose

For many patients with well-controlled asthma taking inhaled corticosteroid/long-acting beta2 agonist combinations or inhaled corticosteroids alone, the inhaled corticosteroid dose can be reduced without loss of asthma control if downward dose adjustments are made gradually.15

The dose can be reduced by stepping down through the available formulations.

Note: TGA-registered fluticasone furoate/vilanterol combinations contain moderate-to-high doses of inhaled corticosteroid (100/25 mcg and 200/25 mcg respectively).

Ceasing inhaled corticosteroid

Patients with well-controlled asthma who stop taking regular low-dose inhaled corticosteroid treatment have an increased risk of flare-ups, compared with those who continue inhaled corticosteroids.4

It may sometimes be necessary to stop treatment temporarily in order to confirm the diagnosis of asthma in a person taking inhaled corticosteroids. In this situation, close monitoring of symptom control is needed.

Table. Confirming the diagnosis of asthma in a person using preventer treatment Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/9

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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Ceasing long-acting beta2 agonist

Patients whose asthma is well controlled with an inhaled corticosteroid/long-acting beta2 agonist combination (either as conventional maintenance treatment plus short-acting beta2 agonist reliever, or as budesonide/formoterol maintenance-and-reliever therapy) can continue taking this regimen long-term. The dose can be reduced by stepping down through the available formulations.

Alternatively, for patients taking an inhaled corticosteroid/long-acting beta2 agonist combination as maintenance treatment, the combination can be replaced with an inhaled corticosteroid inhaler at the same dose. However, a meta-analysis of several studies reported deterioration in asthma control after ceasing long-acting beta2 agonist treatment in patients with asthma previously stabilised on inhaled corticosteroid/long-acting beta2 agonist combination. Therefore, if inhaled corticosteroid/long-acting beta2 agonist is replaced by inhaled corticosteroid only, patients should be advised to start taking their old combination inhaler again if asthma worsens within the first few days after switching.

Note: For patients taking fluticasone furoate/vilanterol, no studies are available to guide stepping down. Options include stepping down to inhaled corticosteroid alone (recommended in the TGA-approved Product Information),6 or stepping down to a different inhaled corticosteroid/long-acting beta2 agonist combination that will achieve a lower inhaled corticosteroid dose. (e.g. Stepping down from treatment with once-daily medium dose fluticasone furoate/vilanterol [100/25 mcg] can be achieved by switching to twice-daily low-dose fluticasone propionate/salmeterol [100/50 mcg or 50/25 mcg]). With either option, patients need careful explanation, including clear written instructions, to avoid potential confusion when changing between inhaler devices and dosing frequencies.

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Safety of stepping down treatment during pregnancy

It may not be feasible to step down (e.g. reduce the inhaled corticosteroid dose or cease long-acting beta2 agonist) during pregnancy, because this is usually accomplished over several months while monitoring asthma control.

Several studies have reported deterioration in asthma control after ceasing long-acting beta2 agonist treatment in adults with asthma previously stabilised on inhaled corticosteroid/long-acting beta2 agonist combination.32 If inhaled corticosteroid/long-acting beta2 agonist combination is replaced by inhaled corticosteroid only, patients should be advised to start taking their old combination inhaler again if asthma worsens within the first few days after switching.

In a woman planning a pregnancy, a failed treatment trial of inhaled corticosteroid alone may demonstrate that she needs to continue taking combination therapy during pregnancy in order to maintain asthma control. 

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Ongoing monitoring of asthma in adults

Asthma monitoring includes both self-monitoring by patients and periodic assessments by the clinician.

Asthma management in primary care should include periodic reassessment of (both):7

  • recent asthma symptom control based on symptoms over the previous 4 weeks, with or without lung function testing. In many patients in primary care, symptoms, reliever use and lung function are useful surrogate measures of the degree to which the underlying disease process is controlled.
  • risk factors that predict poor asthma outcomes (e.g. flare-ups, accelerated decline in lung function, or treatment-related adverse effects) independent of the person’s level of recent asthma symptom control.

Planned asthma check-ups should be made at intervals determined by both the individual’s level of recent asthma symptom control and risk factors. The following is a guide:

  • 1–3 months after each adjustment to medications
  • yearly for a person with no flare-up in the past 12 months and good symptom control for at least a year
  • every 6 months for a person who has had a flare-up within the past 12 months or who has other risk factors for flare-ups or life-threatening asthma (e.g. smoking, previous recording of poor lung function on spirometry, history of admission to an intensive care unit for asthma)
  • at least every 3 months for a person with severe asthma, work-exacerbated asthma, poor perception of airflow limitation, frequent rhinosinusitis symptoms, or other comorbid conditions that affect asthma control
  • every 4–6 weeks for pregnant women.

Note: For patients with occupational asthma, management and follow-up by a specialist with experience in occupational asthma is recommended.

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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.8 Written asthma action plans are effective if based on symptoms9 or personal best peak expiratory flow (not on percentage predicted).8

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: https://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 plans1011 is available online.

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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,1213 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.14 However, a small proportion of individuals may need a higher dose to achieve asthma control.14, 12, 13

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.15
  • 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.15
  • Starting with a moderate dose of inhaled corticosteroid is as effective as commencing with a high dose and down-titrating.15 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,15 but this may not equate to a clinical benefit.

Meta-analyses1617 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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References

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