Asthma Management Handbook
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Table. Australian Asthma Handbook Version 1.3 amendments

Topic

Places(s) in text

Amendment

Rationale

Allergic rhinitis

Managing allergic rhinitis in people with asthma

Addition of new Adults and adolescents and Children subsections in Clinical issues/Allergies/Allergic rhinitis section.

Restructured to clarify advice for different age groups.

Allergic rhinitis

Managing allergic rhinitis in adults and adolescents with asthma

Comorbid conditions and asthma

Assessing allergies to guide asthma management

Managing allergies as part of asthma management

Table. Overview of efficacy of allergic rhinitis medicines for specific symptoms

Figure. Management of allergic rhinitis in adults and adolescents

Amendment of More Information Topics Specific allergen immunotherapy (desensitisation) and Allergic rhinitis and asthma: links, including new title Links between allergic rhinitis and asthma.

Addition of new More Information Topics:

  • Treatment of allergic rhinitis in adults and adolescents
  • Non-recommended medications for allergic rhinitis
  • Nasal saline irrigation for allergic rhinitis
  • Surgical turbinate reduction
  • Smoking and allergic rhinitis

Replacement of all instances of More Information Topic Allergic rhinitis and asthma: treatment with new More Information Topics:

  • Treatment of allergic rhinitis in adults and adolescents
  • Non-recommended medications for allergic rhinitis
  • Nasal saline irrigation for allergic rhinitis
  • Surgical turbinate reduction

Addition of new assets:

  • Figure. Management of allergic rhinitis in adults and adolescents
  • Table. Overview of efficacy of allergic rhinitis medicines for specific symptoms

Deletion of Table. Targeting specific symptoms.

Amendment of recommendations to incorporate updated advice on allergic rhinitis and asthma.

Addition of new recommendations:

Advise patients that intranasal corticosteroids, intranasal antihistamines or oral antihistamines will often relieve eye itching and redness associated with allergic rhinitis without the need for eye drops.

If ocular symptoms are troublesome, consider initial use of topical H1-antihistamines (e.g. azelastine, ketotifen, levocabastine or olopatadine).

If long-term treatment for ocular symptoms is necessary, consider a topical mast-cell stabiliser (e.g. cromoglycate or lodoxamide). Explain that onset of therapeutic effect may take up to 2–4 weeks.

Avoid topical alpha agonist vasoconstrictors (including in combination with antihistamines) because they can cause conjunctivitis medicamentosa.

 

Provide an allergic rhinitis treatment plan.

 

If the response to an intranasal corticosteroid alone is inadequate despite regular daily use and correct spray technique, add an intranasal antihistamine and continue intranasal corticosteroid.

 

If allergic rhinitis symptoms are uncontrolled despite regular use of an intranasal corticosteroid alone or in combination with an intranasal antihistamine, consider specialist referral.

 

Advise patients with allergic rhinitis to avoid tobacco smoke. Explain that smoking worsens both asthma and allergic rhinitis, and can reduce the effectiveness of treatment.

 

Consider nasal irrigation with saline solution or saline nasal sprays as well as drug treatment.

 

Consider specific allergen immunotherapy in patients with allergic rhinitis or allergic asthma who have a history of proven, clinically important sensitisation to a particular allergen that cannot feasibly be avoided and for which specific allergen immunotherapy is available.

 

Warn people with allergic rhinitis and allergy to ryegrass pollen (i.e. most people with springtime allergic rhinitis symptoms) that they may be at risk of thunderstorm-triggered asthma if they live in, or are travelling to, a region with seasonal high grass pollen levels – even if they have never had asthma symptoms before.

 

For all patients at risk of thunderstorm-triggered asthma (e.g. because they have seasonal allergic rhinitis and/or asthma with grass pollen allergy, and are living in or travelling to an area with high grass pollen levels), provide advice on:

  • continual or prophylactic seasonal use of inhaled corticosteroids for asthma, as indicated (see recommendation below)
  • prophylactic seasonal use of intranasal corticosteroid for allergic rhinitis (see recommendation below)
  • asthma first aid for those without known asthma, including how to recognise asthma symptoms, how to get and use a reliever inhaler (ideally with spacer), and when to call an ambulance
  • avoidance – warn against being outdoors just before and during thunderstorms in spring and early summer, especially in wind gusts that precede the rain front.

 

For people with seasonal allergic rhinitis who do not use intranasal corticosteroid treatment all year, advise intranasal corticosteroid starting 6 weeks before the pollen season (or exposure) and continuing until pollen levels abate (e.g. in Victoria, ideally 1 September–31 December).

 

For people with asthma who are at risk of thunderstorm-triggered asthma:

  • prescribe regular inhaled corticosteroids for continuous use if indicated (most adults and older adolescents with asthma)
  • for patients for whom preventer therapy is not otherwise indicated, prescribe regular inhaled corticosteroids for at least 2 weeks before and throughout the pollen season (e.g. in Victoria, ideally 1 September–31 December)
  • provide training in correct inhaler technique, and check technique and adherence regularly
  • advise patients to carry a reliever inhaler and replace it before the expiry date
  • provide an up-to-date written asthma action plan that includes thunderstorm advice and instructs the person to increase doses of both inhaled preventer and reliever (as well as starting oral corticosteroids, if indicated) in response to flare-ups.

Amended to reflect information and advice in updated NAC information paper Managing allergic rhinitis in people with asthma, and new NAC information paper Epidemic thunderstorm asthma.

Allergic rhinitis

Managing allergic rhinitis in children with asthma

Table. Overview of efficacy of allergic rhinitis medicines for specific symptoms

Figure. Management of allergic rhinitis in children under 12 years

 

Amendment of More Information Topic Allergic rhinitis and asthma: links, including new title Links between allergic rhinitis and asthma.

Amendment of More Information Topics Montelukast for children: warning parents about potential psychiatric adverse effects and Specific allergen immunotherapy (desensitisation).

Addition of new More Information Topics:

  • Treatment of allergic rhinitis in children
  • Non-recommended medications for allergic rhinitis
  • Nasal saline irrigation for allergic rhinitis
  • Surgical turbinate reduction
  • Smoking and allergic rhinitis

Replacement of all instances of More Information Topic Allergic rhinitis and asthma: treatment with new More Information Topics:

  • Treatment of allergic rhinitis in children
  • Non-recommended medications for allergic rhinitis
  • Nasal saline irrigation for allergic rhinitis
  • Surgical turbinate reduction

Addition of new assets:

  • Figure. Management of allergic rhinitis in children under 12 years
  • Table. Overview of efficacy of allergic rhinitis medicines for specific symptoms

Deletion of Table. Targeting specific symptoms.

Amendment of recommendations to incorporate updated advice on allergic rhinitis and asthma.

Addition of new recommendations:

In school-aged children with persistent or moderate-to-severe intermittent symptoms, prescribe or recommend an intranasal corticosteroid (even if the child is already using regular inhaled corticosteroids for asthma).

If symptoms do not improve significantly within 3–4 weeks:

  • review the diagnosis
  • check adherence and intranasal administration technique
  • consider allergy testing.

 

In school-aged children with mild intermittent symptoms, consider starting treatment with an intranasal H1-antihistamine, second-generation (less sedating) oral H1-antihistamine or montelukast. Do not use sedating antihistamines.

Montelukast can be considered as an alternative to antihistamines in children with seasonal allergic rhinitis.

If symptoms do not improve significantly within 2–4 weeks, switch to an intranasal corticosteroid.

 

In preschool-aged children or children who will not tolerate intranasal medication, start treatment with a second-generation (less sedating) oral H1-antihistamine approved for use in this ageā€‘group (e.g. cetirizine, desloratadine, fexofenadine, loratadine). Do not use sedating antihistamines.

Montelukast can be considered as an alternative to antihistamines.

If symptoms do not improve significantly within 2–4 weeks, switch to an intranasal corticosteroid if possible.

 

Provide an allergic rhinitis treatment plan

 

In children of any age in whom allergic rhinitis symptoms are uncontrolled despite regular use of intranasal corticosteroids, review the diagnosis and consider specialist referral.

Adenoid hypertrophy should be suspected in children who do not respond to treatment within 4 weeks.

 

For children who are taking an inhaled corticosteroid for asthma and who have persistent allergic rhinitis symptoms despite treatment with an intranasal corticosteroid, consider adding montelukast.

 

At each review, check adherence to medications and topical therapy technique, as for asthma.

 

Consider specific allergen immunotherapy in children with allergic rhinitis who have a history of proven, clinically important sensitisation to a particular allergen that cannot feasibly be avoided and for which for specific allergen immunotherapy is available.

Note: Specific allergen immunotherapy should not be started in children with asthma unless asthma is stable. For those able to perform spirometry, this includes spirometry-demonstrated forced expiratory volume in 1 second (FEV1) greater than 80% predicted for subcutaneous immunotherapy and greater than 70% predicted for sublingual immunotherapy.

 

Advise parents to provide a smoke-free environment for children with allergic rhinitis.

 

Deletion of recommendation:

For young children with mild allergic rhinitis or intermittent allergic rhinitis, or those who will not tolerate intranasal medicines, consider an oral H1-antihistamine. Avoid older, sedating antihistamines.

Amended to reflect information and advice in updated NAC information paper Managing allergic rhinitis in people with asthma, and new NAC information paper Epidemic thunderstorm asthma.

Thunderstorm asthma

Preventing thunderstorm-triggered asthma

Addition of new Thunderstorm asthma subsection in Clinical Issues section.

Reproduction of relevant recommendations and More Information Topics located in other areas of the Handbook.

Restructured to give more prominence to thunderstorm asthma advice.

Thunderstorm asthma

Assessing allergies to guide asthma management

Considering allergen avoidance where feasible

Stepping up treatment in adults

Managing triggers in children

Assessing asthma triggers

Managing avoidable triggers

Table. Summary of asthma triggers

Addition of new More Information Topic Thunderstorm-triggered asthma.

Amendment of Table. Summary of asthma triggers.

Amendment of recommendations to incorporate updated advice on thunderstorm-triggered asthma.

Addition of new recommendations:

Assess and manage the risk of thunderstorm-triggered asthma.

For people with asthma who are at risk of thunderstorm-triggered asthma:

  • prescribe preventer treatment. Most adults and older adolescents should be taking an inhaled corticosteroid all year round. If regular preventer therapy is not otherwise indicated, prescribe regular inhaled corticosteroids throughout the pollen season (in Victoria, ideally 1 September–31 December)
  • provide training in correct inhaler technique, and check technique and adherence regularly
  • advise patients to carry a reliever inhaler and replace it before the expiry date
  • provide an up-to-date written asthma action plan that includes thunderstorm advice and instructs the person to increase doses of both inhaled preventer and reliever (as well as starting oral corticosteroids, if indicated) in response to flare-ups
  • warn to avoid exposure to outdoor air just before and during a thunderstorm, especially during wind gusts just before the rain front hits (e.g. by going indoors with windows closed and air conditioner off or on recirculation mode, or shutting car windows and recirculating air).

For patients who are at risk of thunderstorm-triggered asthma, provide advice on avoiding exposure to outdoor air just before and during a thunderstorm, especially during wind gusts just before the rain front hits (e.g. by going indoors with windows closed and air conditioner off or on recirculation mode, or shutting car windows and recirculating air).

Amended to reflect information and advice in the new NAC information paper Epidemic thunderstorm asthma.

Asthma–COPD overlap

Chronic obstructive pulmonary disease (COPD) and asthma

Considering alternative diagnoses in adults

Other comorbidities and asthma

Investigating new asthma-like symptoms in older adults

Diagnosing and assessing asthma in Aboriginal and Torres Strait Islander people

Figure. Development of asthma, COPD and asthma–COPD overlap

Table. Long-acting bronchodilators for asthma–COPD overlap

Table. Features that, when present, favour either asthma or COPD

Table. Spirometry findings in asthma, COPD and asthma–COPD overlap

 

Replacement of all instances of More Information Topics Coexisting asthma and COPD, Is it asthma, COPD or both? and Management of coexisting asthma and COPD with new More Information Topic Asthma–COPD overlap.

Amendment of More Information Topic Pneumonia risk with inhaled corticosteroids in patients with COPD.

Addition of new assets:

  • Figure. Development of asthma, COPD and asthma–COPD overlap
  • Table. Long-acting bronchodilators for asthma–COPD overlap
  • Table. Features that, when present, favour either asthma or COPD
  • Table. Spirometry findings in asthma, COPD and asthma–COPD overlap

Amendment of overview text on Guide to other asthma medicines page.

Amendment of recommendations to incorporate updated terminology and advice on asthma–COPD overlap.

Addition of new recommendations:

Consider the possibility of asthma–COPD overlap in patients with asthma who also have features of COPD (e.g. adult onset, history of smoking, history of emphysema or chronic bronchitis, limited relief from short-acting bronchodilators, recurrent cough, sputum production).

Consider pulmonary rehabilitation for patients with asthma–COPD overlap, manage comorbidities, and provide advice on physical activity, vaccinations, and self–management. Provide a written action plan. Choose an asthma action plan or a COPD action plan template, depending on the person’s dominant clinical features.

Advise patients to follow their action plan or get medical advice within 24 hours if they develop symptoms that suggest a lower respiratory tract infection (e.g. fever, increased sputum production, worsening shortness of breath).

Consider specialist referral for patients with atypical symptoms or symptoms that suggest an alternative diagnosis, persistent symptoms or flare-ups despite treatment, or complex comorbidities.

Deletion of recommendation:

In addition to prescribing inhaled corticosteroids in combination with long-acting bronchodilators, manage coexisting asthma and COPD according to the individual’s clinical features, comorbidities and response to treatment.

Amended to reflect updated information and advice in new NAC and Lung Foundation Australia information paper Asthma–COPD overlap.

Minor amendments

Asthma triggers

Complementary therapies and asthma

Considering triggers and comorbidities

Table. Options for adjusting medicines in a written asthma action plan for adults

Table. Types of inhaler devices for delivering asthma and COPD medicines

Table. Local pregnancy and breastfeeding safety information services

Amendment of More Information Topic Medicines that can trigger asthma to become two More Information Topics, Aspirin and nonsteroidal anti-inflammatory drugs as asthma triggers and Other medicines that can trigger asthma.

Title change of Table. Summary of efficacy evidence for complementary therapies [in the treatment of asthma].

Title change of Clinical issues/Troubleshooting/Triggers and comorbidities subsection Considering triggers and comorbidities [in troubleshooting].

Addition of Fluticasone and Salmeterol Cipla Inhaler and Fluticasone Cipla Metered-dose Inhaler to relevant tables.

Update of contact details in Table. Local pregnancy and breastfeeding safety information services.

Minor corrections and amendments to improve clarity.

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