Asthma Management Handbook
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Table. Australian Asthma Handbook Version 1.1 clinical amendments

Topic

Place(s) in text

Amendment

Rationale

Definitions

 

Definition of special terms

 

Text inserted:

Control

Asthma control refers to the overall degree to which the impact of asthma, and the risks due to the underlying disease and its treatment, have been reduced or managed for the person.

Assessment of asthma control involves (both of):

  • assessment of recent asthma symptom control (e.g. good, partial or poor), based on frequency of daytime asthma symptoms, night-time symptoms or symptoms on waking, reliever use in response to symptoms, and on limitation of activity
  • assessment of risk factors for future adverse events (e.g. flare-ups, life-threatening asthma, accelerated decline in lung function, or adverse effects of treatment).

Asthma control defined to distinguish between the two separate components of its assessment: (i) control of recent asthma symptoms, and (ii) future risk (risk factors for flare-ups, life-threatening asthma, accelerated decline in lung function, or adverse effects of treatment)

Table. Definitions of asthma patterns in children aged 0–5 years not taking regular preventer

Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Amendment of definition of infrequent intermittent asthma in children:

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Changed from:

Symptom-free for at least 6 weeks at a time (symptoms up to once every 6 weeks on average but no symptoms between flare-ups)

Definition of frequent intermittent asthma in children amended:

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Changed from:

Symptoms more than once every 6 weeks on average but no symptoms between flare-ups

Substitution of ‘symptoms’ for ‘flare-up’ to improve precision of definition

Diagnosis (adults)

Assessing lung function to investigate asthma-like symptoms in adults 

New recommendation:

Record the ratio of FEV1 to FVC (FEV1/FVC). Before making the diagnosis of asthma, confirm that FEV1/FVC is reduced (less than the lower limit of normal for age) at a time when FEV1 is lower than predicted.

Note: If the spirometer does not provide lower limit of normal for age, use the follow age-based cut-points to indicate impairment in adults and older adolescents:

  • less than 0.85 (up to 19 years)
  • less than 0.80 (20–39 years)
  • less than 0.75 (40–59 years)
  • less than 0.70 (60 years and older).

Amendment to clarify role of FEV1/FVC in diagnosis and correct under-emphasis on this parameter in previous version

Amend ‘More information’ topic: 'Definition of variable expiratory airflow limitation'

Text inserted:

Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1 may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC indicates airflow limitation. Normal FEV1/FVC values derived from population studies in adults vary but are usually greater than:

  • 0.85 in people aged up to 19 years
  • 0.80 in people aged 20–39 years
  • 0.75 in people aged 40–59 years
  • 0.70 in people aged 60–80 years.

In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio, because normal values in children change considerably with age.

Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.

Also affects: Diagnosis in children

Additional information provided to support new recommendation for use of FEV1/FVC ratio in the diagnosis of asthma in adults, and to distinguish between roles of FEV1/FVC ratio in the diagnosis of asthma in adults and children

Making a diagnosis of asthma in adults

Recommendation amended:

Make a diagnosis of asthma if all of the following apply:

  • The person has a history of variable symptoms (especially cough, chest tightness, wheeze and shortness of breath).
  • Expiratory airflow limitation has been demonstrated (FEV1/FVC less than lower limit of normal for age).
  • Expiratory airflow limitation has been shown to be variable.
  • There are no findings that suggest an alternative diagnosis.

Note: If the spirometer does not provide lower limit of normal for age, use the follow age-based cut-points to indicate expiratory airflow limitation in adults and older adolescents:

  • less than 0.85 (up to 19 years)
  • less than 0.80 (20–39 years)
  • less than 0.75 (40–59 years)
  • less than 0.70 (60 years and older).

Changed from:

Make a diagnosis of asthma if all of the following apply:

  • The person has variable symptoms (especially cough, chest tightness, wheeze and shortness of breath).
  • Variable airflow limitation is demonstrated.
  • There are no findings that suggest an alternative diagnosis.

Amendment to clarify role of measurement of FEV1/FVC in diagnostic process in adults

Figure. Steps in the diagnosis of asthma in adults

Step headed ‘spirometry’ amended:

FEV1 before and 10–15 minutes after bronchodilator

Reversible airflow limitation? (FEV1 increase ≥200 mL and  ≥12% from baseline)

Expiratory airflow limitation? (FEV1/FVC < lower limit of normal for age)

Changed from:

FEV1 before and 10–15 minutes after bronchodilator

Reversible airflow limitation? (FEV1 increase ≥200 mL and  ≥12% from baseline)

Amended to include FEV1/FVC criterion for expiratory airflow limitation

Table. Confirming the diagnosis of asthma in a person using preventer treatment

Guidance that applies to patients with current respiratory symptoms amended:

Fixed (irreversible or incompletely reversible) airflow limitation (post-bronchodilator FEV1/FVC < lower limit of normal for age and FEV1 < 80% predicted)

Changed from:

Fixed (irreversible or incompletely reversible) airflow limitation (post-bronchodilator FEV1/FVC <0.7 (or < lower limit of normal for age) and FEV1 <80% predicted)

Amended to improve accuracy of FEV1/FVC-based criterion for expiratory airflow limitation

Management (children and adults)

Table: Steps for conducting a treatment trial

Text amended:

Run treatment trial for agreed period (e.g. 4–8 weeks, depending on the treatment and clinical circumstances, including urgency).

Changed from:

Run treatment trial for agreed period (e.g. 6–8 weeks)

Duration of treatment trials amended for consistency with guidance on a wider range of medicines, and qualified for clarity

Management (adults)

Stepping up treatment in adults 

Recommendation amended:

If asthma is only partly controlled despite low-dose inhaled corticosteroids, good adherence and correct inhaler technique, consider stepping up to a low dose of an inhaled corticosteroid/long-acting beta2 agonist combination.

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

Changed from:

If asthma is only partly controlled despite low-dose inhaled corticosteroids, good adherence and correct inhaler technique, consider stepping up to an inhaled corticosteroid/long-acting beta2 agonist combination.

Clarification of inhaled corticosteroid/long-acting beta2 agonist combination dose recommendation for increasing treatment, in response to introduction in late 2014 of a new inhaled corticosteroid/long-acting beta2 agonist combination (fluticasone furoate/vilanterol), of which both TGA-registered formulations contain a moderate or high dose of inhaled corticosteroid

Amend ‘More information’ topic: 'Inhaled corticosteroid/long-acting beta-2 agonist combinations for adults: stepping up from inhaled corticosteroid alone'

Text inserted:

The fluticasone furoate/vilanterol combination is suitable only for patients who require a moderate-to-high dose of inhaled corticosteroid in combination with a long-acting beta2 agonist. It should be prescribed only as one inhalation once daily. The higher dose of fluticasone furoate/vilanterol (200/25 microg) should not be used for patients with asthma who also have COPD, because of the increased risk of pneumonia.

Amended to include fluticasone furoate/vilanterol combination (introduced in late 2014)

Stepping down treatment in adults

Text inserted after recommendation:

  • The fluticasone furoate/vilanterol combination is not available in a low dose

Amendment to explain role of fluticasone furoate/vilanterol combination (introduced in late 2014)

New recommendation:

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

Amended to distinguish between adults and adolescents

New recommendation:

For adults with a confirmed asthma diagnosis taking low-dose inhaled corticosteroid alone, maintain treatment long term.

  • Many patients who experience few asthma symptoms stop taking preventer treatment without discussing with their prescriber.

Amended to provide explicit advice against cessation of inhaled corticosteroids in adults without a significant clinical reason

Recommendation amended:

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.

Changed from:

If a patient has experienced good asthma control for 2–3 months and has no risk factors for flare-ups, consider stepping down by one step.

Amended to distinguish stepping down to low-dose inhaled corticosteroid from cessation of inhaled corticosteroid, consistent with new recommendations, and to clarify the risk criterion for stepping down

Recommendation amended:

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

Changed from:

For adults with a confirmed asthma diagnosis taking low-dose inhaled corticosteroid alone, maintain treatment long term.

Amended to explain the aim of continuing low-dose inhaled corticosteroid treatment.

Recommendation amended:

For patients taking low-dose combination inhaled corticosteroid/long-acting beta2 agonist, 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.

Changed from:

For patients taking combination low-dose inhaled corticosteroid/long-acting beta2 agonist, consider either of the following options if asthma is well controlled:

  • maintain this treatment long term
  • replace combination inhaler with an inhaled corticosteroid at the same dose.

Time interval specified to provide more precise guidance

Amend ‘More information’ topic: 'Stepping down regular asthma medicines in adults'

Notes inserted:

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

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), 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 microg) can be achieved by switching to twice-daily low-dose fluticasone propionate/salmeterol (100/50 microg or 50/25 microg). With either option, patients need careful explanation, including clear written instructions, to avoid potential confusion when changing between inhaler devices and dosing frequencies.

Amendments to explain role and use of fluticasone furoate/vilanterol combination (introduced in late 2014) which, unlike previously available inhaled corticosteroid/long-acting betaagonists, is not available in a low dose formulation.

Amend ‘More information’ topic: 'Stepping down regular asthma medicines in adults'

Text inserted:

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.

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.

Amended to support new recommendation to maintain low-dose inhaled corticosteroid treatment long term in adults with a confirmed asthma diagnosis

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

New row inserted for fluticasone furoate/vilanterol

Amended to include fluticasone furoate/vilanterol combination (introduced in late 2014)

Managing high-risk and difficult-to-control asthma in adults 

New recommendation:

The fluticasone furoate/vilanterol combination can be considered for patients with asthma who need a medium-to-high dose of inhaled corticosteroid in combination with a long-acting beta2 agonist as their usual maintenance treatment.

  • Fluticasone furoate/vilanterol should be taken as one inhalation once daily. Warn patients not to take more inhalations or more frequent doses.

Amended to explain role of fluticasone furoate/vilanterol combination (introduced in late 2014)

Prescribing inhaled corticosteroid-based preventers for adults

 

 

Amend More-information topic: 'Inhaled corticosteroids for adults: overview'

Text inserted:

Inhaled corticosteroid preventers available in Australia

The following inhaled corticosteroids are registered by the TGA:

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

Amended to clarify roles of inhaled corticosteroids, including fluticasone furoate/vilanterol combination (introduced in late 2014)

Amend More-information topic: 'Inhaled corticosteroid/long-acting beta-2 agonist combinations for adults: overview'

Text amended:

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

Changed from:

Less evidence from double-blind randomised controlled clinical trials is available for the newer combination of fluticasone propionate and eformoterol.

Text inserted:

The fluticasone furoate/vilanterol combination is equivalent to a medium-to-high dose of inhaled corticosteroids. In adults and adolescents already taking inhaled corticosteroids, once-daily fluticasone furoate/vilanterol 100/25 microg reduced the risk of severe flare-ups (requiring oral corticosteroids or hospitalisation) and improved lung function, compared with fluticasone furoate alone. Efficacy data for the comparison of fluticasone furoate/vilanterol with other inhaled corticosteroid/long-acting beta2 agonist combinations are not available.

Amended to include fluticasone furoate/vilanterol combination (introduced in late 2014)

Table. Definitions of ICS dose levels in adults

Row inserted for fluticasone furoate

Footnote inserted:

Fluticasone furoate is available only in combination with vilanterol (a long-acting beta2 agonist), and is not available as a low dose. It should only be prescribed as one inhalation once daily.

Amended to include fluticasone furoate/vilanterol combination (introduced in late 2014)

Table. Types of inhaler devices for delivering asthma medicines

Row inserted for fluticasone furoate/vilanterol combination

 

Amended to include fluticasone furoate/vilanterol combination (introduced in late 2014)

Management (children)

 

Reviewing initial treatment in children 0–5 years 

 

Recommendations amended:

When prescribing any preventer medicine for a child, consider each treatment adjustment as a treatment trial: monitor response continually, review within 4 weeks, and adjust treatment according to response.

If symptoms have been well controlled for at least 3 months in a child taking regular inhaled corticosteroid treatment, reduce the dose to find the minimal dose needed to control symptoms.

If symptoms are well controlled for at least 3 months on the lowest available inhaled corticosteroid dose, consider the following options:

  • Stop preventer treatment completely, while monitoring the response, to judge whether symptoms have resolved.
  • Replace inhaled corticosteroid with a trial of montelukast or a cromone. If well controlled for a further 3 months, stop preventer treatment and monitor the response.

Changed from:

When prescribing any preventer medicine for a child, consider each treatment adjustment as a treatment trial:

  • Review within 4 weeks
  • Monitor continually and adjust treatment according to response
  • If symptoms remain well controlled, continue reducing the dose to find the lowest dose needed to maintain symptom control.

If symptoms have been controlled for at least 3 months in a child taking regular inhaled corticosteroid treatment, back-titrate the dose:

  • Reduce the dose to find the minimal dose needed to control symptoms
  • If well controlled on low dose, consider stopping treatment completely to judge whether symptoms have resolved.

Amended to clarify that low-dose inhaled corticosteroid should not be continued indefinitely in children and to distinguish between the use of inhaled corticosteroids and that of other preventers in children

Table. Initial preventer treatment for children aged 0–5 years

Row for children aged 1–2 years with persistent asthma amended:

Consider a treatment trial with sodium cromoglycate 10 mg three times daily and review response in 2–4 weeks

Changed from:

Consider a treatment trial with a cromone (sodium cromoglycate or nedocromil) and review response in 2–4 weeks

Footnote text inserted:

Starting dose sodium cromoglycate 10 mg (two inhalations of 5 mg/actuation inhaler) three times daily. If good response, reduce to 10 mg twice daily when stable.

Recommendation for use of nedocromil in children aged less than 2 years deleted in line with TGA-approved indication

Dose provided for sodium cromoglycate

 

Table. Initial preventer treatment for children aged 6 years and over 

Footnote text inserted:

e.g. sodium cromoglycate 5 mg/actuation; 10 mg (two inhalations) three times daily, then 10 mg twice daily when stable.

Dose provided for sodium cromoglycate

Conducting further review after adjustment of initial treatment in children 6 years and over

 

New recommendations:

If symptoms have been controlled for at least 3 months in a child taking regular low-dose inhaled corticosteroid/long-acting beta2 agonist combination, consider replacing with (one of):

  • low-dose inhaled corticosteroid and concomitant montelukast
  • low-dose inhaled corticosteroid
  • montelukast
  • a cromone.

If symptoms are well controlled for at least 3 months on the lowest available inhaled corticosteroid dose, consider the following options:

  • Stop preventer treatment completely, while monitoring the response, to judge whether symptoms have resolved.
  • Replace inhaled corticosteroid with a trial of montelukast or a cromone. If well controlled for a further 3 months, stop preventer treatment and monitor the response.

Recommendation expanded to provide more details on treatment options at same step and avoid unintended inference that preventer treatment should be continued indefinitely in children

Acute asthma

Continuing treatment and considering additional treatment 

 

 

 

 

Recommendation amended:

For adults with severe or life-threatening acute asthma, or with poor response to repeated maximal doses of other bronchodilators, consider intravenous magnesium sulfate. Give magnesium sulfate 10 mmol diluted in a compatible solution as a single infusion over 20 minutes.

Changed from:

For adults with severe or life-threatening acute asthma, or with poor response to repeated maximal doses of other bronchodilators, consider intravenous magnesium sulfate. Give magnesium sulfate 2 g diluted in saline as a single infusion over ≥20 minutes.

Dose revised and units replaced to facilitate implementation

Recommendation amended:

For children 2 years and older with poor response to initial bronchodilator therapy, consider intravenous magnesium sulfate. Give magnesium sulfate 0.1–0.2 mmol/kg (maximum 10 mmol) diluted in a compatible solution as a single infusion over 20 minutes.

Changed from:

For children 2 years and older with poor response to initial bronchodilator therapy, consider intravenous magnesium sulfate. Give magnesium sulfate 0.1–0.2 mmol/kg diluted in saline as a single infusion over ≥ 20 minutes.

Maximum dose provided

Practical information added to facilitate implementation

New table:

How to administer intravenous magnesium sulfate

Practical information added to facilitate implementation

Recommendation amended:

In critical care units (e.g. emergency department, intensive care unit, high-dependency unit), IV salbutamol can be considered for patients with life-threatening acute asthma that has not responded to continuous nebulised salbutamol, after considering other add-on treatment options.

  • Salbutamol toxicity can occur with either the inhaled or IV route of administration. Risk may be increased when the inhaled and IV routes are used concomitantly.

Changed from:

In critical care units (e.g. emergency department, intensive care unit, high-dependency unit), IV salbutamol can be considered for patients with life-threatening acute asthma that has not responded to continuous nebulised salbutamol, after considering other add-on treatment options.

For adults and children, give an initial loading dose of 5 microg/kg/min for 1 hour then reduce to 1–2 microg/kg/min until breathing stabilises. Then wean off.

Monitor blood electrolytes, heart rate and acid/base balance (blood lactate).

  • Salbutamol toxicity may occur with inhaled and IV salbutamol.

Dosage moved to separate recommendation to distinguish role of IV salbutamol from delivery

Alert revised to clarify risk according to route of administration 

New recommendation:

If using IV salbutamol to manage acute asthma, follow your hospital/organisation’s protocol for dosage and delivery.

If no local protocol is available, use the following as a guide:
Using a 1 mg/mL (1000 microg/mL) salbutamol concentrate for infusion, prepare a solution of 5 mg in 50 mL normal saline. Deliver by continuous infusion or bolus.

Children 2–12 years:
Loading dose of 5 microg/kg/minute (maximum 200 microg/minute) for 1 hour and then infusion of 1–2 microg/kg/minute (maximum 80 microg).

Adults and children older than 12 years:
As continuous infusion: initial loading dose of 200 microg over 1 minute and then start infusion at 5 microg/minute (can increase to 10 microg/minute, then up to 20 microg/minute every 15–30 minutes according to response)
As bolus: 250 microg over 5 minutes.

  • The initial dose should be reduced for older adults. Dose reduction may be needed for people with impaired renal function. Impaired liver function may result in accumulation of unmetabolised salbutamol. Refer to TGA-approved product information.

Monitor blood electrolytes, heart rate and acid/base balance (blood lactate).

  • Salbutamol toxicity can occur with either the inhaled or IV route of administration. Risk may be increased when the inhaled and IV routes are used concomitantly.

Dosage and delivery protocol provided as separate recommendation to distinguish from role of IV salbutamol

New protocol recommendation to acknowledge lack of evidence and clinical consensus on the use of IV salbutamol

Suggested dose revised and maximum dose provided for children

 

Amend ‘More information’ topic: 'Salbutamol in acute asthma: route of administration'

Text inserted:

[…] However, there is a lack of consensus on the appropriate dose of IV salbutamol for children. Recommendations differ between guidelines in Australia and elsewhere. Doses have not been calculated based on age-specific pharmacokinetic and pharmacodynamic data. The doses recommended in guidelines are generally relatively higher than for adults on a micrograms per kilogram body weight basis.

Insertion of text to acknowledge lack of evidence and clinical consensus on the use of IV salbutamol in children

Completing secondary assessments and reassessing severity 

and

Assessing response to treatment

New recommendations:

In non-acute care settings (e.g. general practices), arrange transfer to acute care facility if no improvement or worsening. Call ambulance (000) and continue administering bronchodilator while waiting.

In acute care facilities, arrange transfer to higher-level care if worsening

Amendments acknowledge that higher-level care is not necessarily intensive care unit in all acute care settings, and to clarify management of acute asthma that is initially assessed as mild/moderate or severe but does not improve after initial bronchodilator treatment

Figure. Managing acute asthma in adults

and

Figure. Managing acute asthma in children 

Text amended:

Transfer to higher-level care

Changed from:

Transfer to ICU

Text inserted:

In non-acute care settings, arrange immediate transfer to acute care if no improvement

Arrange immediate transfer to higher-level care if no improvement or worsening

Amendments acknowledge that higher-level care is not necessarily intensive care unit in all acute care settings, and to clarify management of acute asthma that is initially assessed as mild/moderate or severe but does not improve after initial bronchodilator treatment

Figure. Initial management of life-threatening acute asthma

Doses of IV magnesium sulfate amended:

Dilute in compatible solution as single infusion over 20 minutes

Adults and adolescents: 10 mmol

Children 2–12 years: 0.1–0.2 mmol/kg (maximum 10 mmol)

Guidance for use of IV salbutamol amended:

Follow your hospital/organisation’s protocol for dosage and delivery.

Figure amended in line with amendments in dose and protocol recommendations

Table. Add-on treatment options for acute asthma 

Doses of IV magnesium sulfate amended:

IV infusion over 20 minutes

Adults: 10 mmol

Children 2 years and over: 0.1–0.2 mmol/kg (maximum 10 mmol)

Dilute in compatible solution

Guidance for use of IV salbutamol amended:

Follow hospital/organisation’s protocol.

Table amended in line with amendments in dose and protocol recommendations

Clinical issues

Managing coexisting asthma and COPD

 

Amend ‘More information’ topic: 'Pneumonia risk with inhaled corticosteroids in patients with COPD'

Text amended:

Pneumonia risk with inhaled corticosteroids in patients with COPD

In people with COPD, the risk of pneumonia is increased by the use of regular inhaled corticosteroids, predominantly fluticasone propionate. Increased pneumonia rates have also been observed in studies of patients with COPD using fluticasone furoate/vilanterol. The higher dose of fluticasone furoate/vilanterol (Breo Ellipta 200/25 microg) is not indicated for patients with COPD.

Increased risk of pneumonia with inhaled corticosteroids has not been established in patients with asthma. However, the risk of pneumonia in patients with co-existing asthma and COPD is unknown, so caution is advised, particularly if high doses are being considered.

Changed from:

Safety considerations for inhaled corticosteroids in COPD

In people with COPD, the risk of pneumonia is increased by the use of regular inhaled corticosteroids, predominantly fluticasone propionate. There is no evidence of increased risk of pneumonia with inhaled corticosteroids in patients with asthma. However, the risk of pneumonia in patients with co-existing asthma and COPD is unknown.

Amended to include additional data for fluticasone furoate/vilanterol combination (available from late 2014)

Healthy eating for asthma

and

Table. Preventive healthcare in people with asthma

Recommendation amended:

Encourage healthy eating for all patients with asthma. Explain that there is emerging evidence that some healthy eating habits may also help with lung health:

  • eating plenty of fruit and vegetables every day
  • minimising intake of processed and take-away foods that are high in saturated fats.

Changed from:

Encourage healthy eating for all patients with asthma. Emphasise:

  • eating plenty of fruit and vegetables every day
  • eating fish often
  • minimising intake of saturated fats.

Amended following reappraisal of evidence

Amend ‘More information’ topic: 'Vitamin D'

Insertion of text:

Another recent study failed to show any decrease in the rate of asthma flare-ups with vitamin D supplementation, although exploratory analysis of the results suggested that vitamin D supplementation a reduced the rate of asthma flare-ups only in adults who had an increase in circulating vitamin D levels after supplementation.

Amended to incorporate new evidence

Table. Summary of asthma triggers

Deletion of ‘Beta blockers’ from category ‘Unavoidable triggers’.

Insertion of ‘Beta blockers’ to category ‘Avoid or reduce where possible’

Beta blockers moved to higher-caution category due to international concern about risk in people with asthma

Populations

Assessing and managing asthma in adolescents and young adults

Recommendation amended:

For adolescents taking regular inhaled corticosteroid whose asthma has been well controlled for at least 3 months, try reducing the dose or stepping down by one step while monitoring. If well controlled for at least 3 months on the lowest dose, consider a trial cessation of inhaled corticosteroid.

Note: For those in mid-to-late adolescence, follow the guidance for adults

Figure. Stepped approach to adjusting asthma medication in adults

Figure. Stepped approach to adjusting asthma medication in children

Changed from:

If asthma has been stable for several months, attempt to back-titrate the dose

Amended to clarify implementation of recommendation

Prevention

Prenatal care for women concerned about their children’s asthma risk

Heading amended:

Prenatal care for women concerned about their children’s asthma risk

Changed from:

Prenatal strategies for preventing asthma risk in children

Page heading modified to avoid unintended inference that all strategies mentioned are effective and recommended for primary prevention of asthma

Amend ‘More information’ topic: 'Risk factors for developing asthma'

Heading amended:

Factors reported to be associated with increased risk of developing asthma

Changed from:

Risk factors for developing asthma

Text inserted:

Avoidance of these ‘risk’ factors has either not been investigated in good quality studies, or has not been shown to prevent asthma and is not recommended for prevention of asthma.

Insertion of text before list of factors reported to be associated with reduced risk of developing asthma:

Observational studies have identified various factors associated with reduced risk of developing asthma. However, deliberate exposure to these ‘protective’ factors has not been shown to prevent asthma and is not recommended for asthma prevention.

‘Consumption of unpasteurized cow’s milk’ deleted from list of factors

Clarification that associations observed in observational studies do not prove causality, or justify potentially harmful avoidance or exposure

Consumption of unpasteurised milk is unsafe, there is potential for harm if consumed by pregnant women or by children, and there is only limited low-level evidence for its effect on asthma risk

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