Asthma Management Handbook
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Table. Australian Asthma Handbook Version 1.2 clinical amendments

Topic

Places(s) in text

Amendment

Rationale

Written asthma action plans

Management of asthma

Addition of new Written asthma action plans subsection in Management section.

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

Restructured to give more prominence to the central recommendation that every patient should have a personalised written asthma action plan.

Regular preventer treatment in adults

General considerations when prescribing regular preventer treatment for adults

Prescribing inhaled corticosteroid-based preventers for adults

Stepping down treatment in adults

Amendment of recommendations and More Information Topic Stepping down regular asthma medicines in adults, including addition of Table (Asset ID) 22. Definitions of ICS doses levels in adults, and addition of relevant More Information Topics for clarification on long-term low-dose ICS.

Addition of new recommendation:

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.

Amended to clarify advice about long-term ICS use to:

  • confirm that long-term use (including lifetime) may be needed
  • emphasise that the purpose is to reduce future risk rather than to treat current symptoms.

Provision of more detailed guidance on what is meant by low dose for ICS in adults.

Stepped approach to adjusting asthma medications in adults

Figure. Stepped approach to adjusting asthma medications in adults

Amendment of step 1 footnote and step 3 to specify different regimens for ICS/LABA combinations:

Low dose budesonide/formoterol combination only applies to patients using this combination in a maintenance-and-reliever regimen. (This combination is not classed as a reliever when used in a maintenance-only regimen.)

ICS/LABA combination (low dose) as maintenance therapy OR budesonide/formoterol (low dose) as maintenance and reliever therapy.

Deletion of montelukast from step 3 and footnotes.

Amended to clarify the different regimens for ICS/LABA combinations.

Amended to improve consistency with remainder of figure and other advice on montelukast for adults.

Stepping down preventer treatment in adults

Stepping down treatment in adults

Amendment of recommendations including addition of alert:

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.

Reproduction of recommendation and More Information Topic on stepping down medications in pregnancy from section Managing Asthma in Pregnancy.

Amended to provide more detailed guidance on implementation of stepping down recommendations.

Fluticasone furoate

Guide to preventer medicines

Table. Definition of ICS dose levels in adults

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

Amendment of More Information Topics Inhaled corticosteroids for adults: overview.

Amendment of tables to ensure distinction between fluticasone furoate and fluticasone furoate/vilanterol combination.

Amended to include new medication fluticasone furoate (TGA approval in 2016).

Severe and difficult-to-treat asthma

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

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

Addition of reference to recommendations and change of recommendation type from Consensus-based recommendation: opinion and experience to Consensus-based recommendation: opinion and experience with reference to selected sources.

Addition of ‘severe’ to page title Managing [severe,] high-risk and difficult-to-control asthma in adults and More Information Topic title Definitions of [severe and] difficult-to-treat asthma.

Amendment of More Information Topic Definitions of severe and difficult-to-treat asthma.

Amended to incorporate current European Respiratory Society and American Thoracic Society guidelines, International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma.

Severe and difficult-to-treat asthma

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

Deletion of 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 avoid unintended inference that the fluticasone furoate/vilanterol combination is recommended over other combinations for adults who need a medium to high dose of ICS.

Tiotropium

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

Addition of new recommendation:

Tiotropium can be considered as an add-on option in adults who have had a severe asthma flare-up despite maintenance treatment with high-dose inhaled corticosteroid in combination with a long-acting beta2 agonist.

Amendment of More Information Topic Tiotropium for adults.

Amended to include updated indications for tiotropium (TGA approval in 2015).

Mepolizumab

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

Managing allergies as part of asthma management

Addition of new recommendation:

Mepolizumab can be considered as an add-on treatment for patients aged 12 years and over with severe refractory eosinophilic asthma.

Addition of More Information Topic Mepolizumab.

Amended to include new medication mepolizumab (TGA approval in 2016).

Omalizumab

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

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

Managing allergies as part of asthma management

Amendment of adults and adolescents recommendations.

Addition of new recommendation:

Omalizumab treatment can be considered for children aged 6 to 11 years with severe allergic asthma (documented exacerbations despite daily high-dose inhaled corticosteroids) and raised IgE levels.

Amendment of More Information Topic Omalizumab for adults and adolescents, including change in title to Omalizumab.

Amended to include updated indications for omalizumab (TGA approval in 2016).

Amended to clarify that once omalizumab treatment is established in adults and adolescents, ongoing treatment may be administered by a local doctor.

Specific allergen immunotherapy

Managing allergies as part of asthma management

Amendment of More Information Topic Specific allergen immunotherapy (desensitisation).

Amendment of recommendation note to:

Both forms of specific allergen immunotherapy require at least 3 years of treatment and should be initially prescribed by an allergy specialist (allergist or clinical immunologist) where possible. Sublingual therapy for house dust mite allergic asthma is only approved for patients who also have allergic rhinitis, and whose asthma is not well controlled with inhaled corticosteroids.

For patients with unstable asthma (e.g. frequent symptoms, marked variability in airflow measured by spirometry or peak flow monitor), the risks of treatment should be considered, and they will need specialist supervision during treatment.

Amended to include new sublingual (specific allergen) immunotherapy preparations.

Amended to clarify that specific allergen immunotherapy should be prescribed initially by an allergy specialist where possible.

Specific allergen immunotherapy

Managing allergies as part of asthma management

Asthma prevention in children at risk of developing asthma

Amendment of recommendations.

Amendment of More Information Topic Specific allergen immunotherapy (desensitisation).

Deletion of More Information Topic Specific allergen immunotherapy in children.

Replacement of all instances of More Information Topic Specific allergen immunotherapy in children with More Information Topic Specific allergen immunotherapy (desensitisation).

Amended to remove duplication and to clarify information on allergen immunotherapy in children.

Inhaler devices and technique

Inhaler devices and technique

Medicines guide

Managing asthma in children

Prescribing inhaled corticosteroid-based preventers for adults

Table. Types of spacers

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

Table. Considerations for choice of inhaler device type when prescribing inhaled medicines

Table. Classification of asthma medicines

Table. Considerations when choosing inhaler devices for older patients

Amendment of overview text on Inhaler devices and technique and Guide to other asthma medicines pages.

Amendment of recommendations and tables on relevant pages.

Addition of new table Types of spacers [Asset ID 98].

Replacement of Table. Types of inhaler devices for delivering asthma and COPD medicines with equivalent table from information paper [Asset ID 75].

Amendment of More Information Topics:

  • Correct use of inhaler devices
  • Technical notes: pressurised metered-dose inhalers with spacers
  • Administration of inhaled medicines in children: 0-5 years
  • Administration of inhaled medicines in children: 6 years and over
  • Choosing inhaler devices for older adults
  • Preparation of new spacers

Amended to reflect updated NAC information paper Inhaler technique for people with asthma or COPD.

Clarification of advice on priming new spacers.

Control checklists and questionnaires

Planning asthma review and follow-up

Conducting asthma review at scheduled asthma visits

Asthma control questionnaires (previously Asthma Score)

Addition of new recommendation:

Validated checklists or questionnaires can be used at each visit to assess recent asthma symptom control or to screen for poor asthma control, e.g.:

  • Asthma Score (Asthma Control Test)
  • Primary care Asthma Control Screening
  • Asthma Control Questionnaire

Amendment of More Information Topics:

  • Omalizumab for adults and adolescents
  • Assessing recent asthma control in adults: symptoms
  • Approaches to assessment and monitoring of asthma control in children

Update of Asthma Score to the validated Australian version.

Amended to clarify and update information on the Asthma Control Questionnaire (ACQ) and Asthma Score (Asthma Control Test), including:

  • that ACQ-5 is required to establish eligibility for reimbursement for omalizumab
  • update of the Asthma Score (Asthma Control Test) to the current Australian version
  • note that clinicians and researchers must use the Australian versions of ACQ and Asthma Score, and that the questionnaire wording and layout must not be changed.

Investigations

Table. Risk factors for adverse asthma outcomes in adults and adolescents

Amendment of table and addition of footnote: White cell differential count on a peripheral blood sample is not routinely recommended in the investigation and management of asthma, except for patients with severe refractory asthma. In research studies, peripheral blood eosinophilia suggests the presence of eosinophilic airway inflammation.

Amended to avoid unintended inference that blood eosinophil count is a routine test asthma management.

Beta-blockers

Asthma triggers

Amendment of recommendation:

If a patient with asthma has a condition for which treatment with a beta blocker is advisable, choose a cardioselective agent if possible (e.g. atenolol, bisoprolol, metoprolol, nebivolol), but consider the risks, ensure supervision and monitoring of asthma, and warn patients (including those taking ocular preparations) about the risk of serious asthma flare-ups.

Amendment of More Information Topic Medicines that can trigger asthma.

Amended to clarify safety concerns for beta blockers.

Asthma and COPD

Chronic obstructive pulmonary disease (COPD) and asthma

Considering alternative diagnoses in adults

Diagnosing and assessing asthma in Aboriginal and Torres Strait Islander people

Amendment of overview text on Chronic obstructive pulmonary disease (COPD) and asthma page.

Title change of Clinical issues/COPD subsection from Managing asthma with COPD to Asthma–COPD overlap.

Amendment of recommendations and addition of More Information Topic Is it asthma, COPD or both? on relevant pages.

Amendment of More Information Topics:

  • Is it asthma, COPD or both?
  • Coexisting asthma and COPD
  • Management of coexisting asthma and COPD
Amended terminology to change the emphasis from concurrent asthma and COPD (two diagnoses in same patient) to asthma–COPD overlap (a range of clinical entities).

e-cigarettes

Smoking and asthma

Addition of text on overview page.

Addition of new recommendation:

Do not encourage the use of electronic cigarettes, even for the purpose of smoking cessation.

Addition of new More Information Topic Electronic cigarettes (e-cigarettes).

Additions to acknowledge the increasing use of e-cigarettes and provide interim consensus advice until more evidence becomes available.

Oxygen therapy in acute asthma

Completing a rapid primary assessment and starting initial treatment

Completing secondary assessments and reassessing severity

Figure. Managing acute asthma in adults

Figure. Managing acute asthma in children

Amendment of Primary assessment recommendation:

Start oxygen therapy for all patients with severe or life-threatening acute asthma. Titrate oxygen saturation to target of 92–95% for adults and at least 95% for children.

  • In adults, avoid over-oxygenation, because this increases the risk of hypercapnoea
  • For children, consider whether humidification of oxygen is indicated

Amendment of Secondary assessment recommendation:

For adults and children, start titrated oxygen therapy for all patients with severe or life-threatening acute asthma. Maintain oxygen saturation of 92–95% for adults and at least 95% for children.

  • Excessive oxygen administration can lead to hypercapnoea in people with asthma and COPD

Amendment of corresponding figures.

Amended to simplify and rationalise regimen to base initial supplementary oxygen therapy on assessed severity category (all severe or life-threatening) not on oxygen saturation.

Post-acute care

Providing post-acute care

Amendment of recommendations and More Information Topic Interim asthma action plans for greater clarity.

Amended to increase prominence of advice to acute care facilities to ensure that high doses of reliever given or prescribed during acute asthma are stopped after discharge. 

Montelukast

Managing asthma in children

Managing exercise-induced bronchoconstriction in children

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

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

Table. Reviewing and adjusting preventer treatment for children aged 0–5 years

Table. Reviewing and adjusting preventer treatment for children aged 6 years and over

Table. Step-up options for children when good asthma control is not achieved with low-dose ICS

Table. Managing persistent exercise-induced respiratory symptoms in children

Addition of alert to relevant recommendations and tables:

Advise parents about potential adverse psychiatric effects of montelukast.

Title change of More Information Topic Montelukast for children: [warning parents about potential] psychiatric [adverse] effects and addition of link to TGA’s safety update on montelukast and neuropsychiatric risks.

Addition of More Information Topic Montelukast for children: warning parents about potential psychiatric adverse effects to relevant pages.

Amended to increase prominence of warnings about potential psychiatric adverse effects of montelukast.

Montelukast

Table. Step-up options for children when good asthma control is not achieved with low-dose ICS

Amendment of ‘PBS considerations’ column with updated PBS status.

ICS plus montelukast:

  • 2–5 years: not subsidised
  • 6–14 years: not subsidised unless for exercise-induced bronchoconstriction despite ICS treatment
  • 15 years and over: not subsidised

Amended to update PBS status for montelukast used in combination with ICS.

Spirometry

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

Amendment of table and addition of footnote:

When spirometry is performed as a diagnostic test, inhaled bronchodilators should be withheld before the test. Withholding times vary between medicines:

  • at least 4 hours for SABAs (e.g. salbutamol, terbutaline) and SAMAs (e.g. ipratropium)
  • at least 12 hours for preventers containing LABAs for which twice-daily dosing is recommended (e.g. formoterol, salmeterol)
  • at least 24 hours for LAMAs (e.g. aclidinium, glycopyrronium, tiotropium) and preventers containing LABAs with once-daily dosing (e.g. fluticasone furoate plus vilanterol).

Amended to include withholding times for different bronchodilators when spirometry is performed as a diagnostic test.

Primary prevention

Infant feeding and asthma prevention

Prenatal advice for women concerned about their children’s risk of developing asthma

Amendment of recommendations and More Information Topics to incorporate updated infant feeding and allergy prevention advice from ASCIA.

Amendment of More Information Topics:

  • Breastfeeding and allergy prevention
  • Hypoallergenic infant formula and allergy prevention
  • Dietary restriction during pregnancy for allergy prevention
  • Dietary supplementation during pregnancy and in newborns

Deletion of recommendation:

If pregnant women with allergies or asthma are motivated to try allergen avoidance to reduce their baby’s asthma risk, advise that a comprehensive multi-allergen avoidance program, beginning during pregnancy or at birth, may reduce the risk of asthma in later childhood. This would involve low-allergen infant feed (breastfeeding by mother on a low-allergen diet, or partially hydrolysed [‘hypoallergenic’] formula) and house dust mite avoidance (as a minimum, acaricide and impermeable mattress covers).

Warn parents that multi-allergen avoidance strategies may be time-consuming and expensive, may not be feasible in Australia, and may not prevent the development of asthma in individual children.

Amended to reflect updated guidelines from Australasian Society of Clinical Immunology and Allergy (ASCIA) Infant feeding and allergy prevention.

Asset ID: 99