Balancing the Benefits: Asthma and Combination Therapy Update

By Adem Lewis / in , , /

Hello, I’m Norman Swan.
Welcome to this asthma update. There are more than two million
Australians living with asthma. One of the biggest changes in treatment
over the last few years has been the introduction
of combination therapies. That’s what tonight’s program
is about. It’s sponsored by
the National Asthma Council Australia, with unrestricted funding
from AstraZeneca. We’re coming to you live
across Australia through the Rural Health Education
Foundation’s satellite network. There are a number of resources
available on the Rural Health Education
Foundation’s website: Let’s meet our panel. Matthew Peters is an associate professor
in Respiratory Medicine at the University of Sydney,
and a respiratory physician at Concord Hospital in Sydney. – Welcome, Matthew.
– Good evening. Clive Tucker is a general practitioner
from rural south-east Queensland, whose experience includes
conducting respiratory clinics with the South African army. – Welcome, Clive.
– Thanks. – Are there many wheezing conscripts?
– Millions. Stephen Hughes is a community pharmacist
from Petersham in Sydney. – Welcome, Stephen.
– Norman. Stephen’s an old hand at these programs
to do with asthma. And Judi Wicking is an asthma educator
running clinics in general practice, and a project officer with the National
Asthma Council Australia. Welcome. What are we talking about, when we’re
talking about combination therapy? We’re talking about some of the more
modern asthma treatments that combine
a long-acting bronchodilator or a long-acting
Ventolin-type preparation in conjunction with a very effective
inhaled corticosteroid medication. For patients with
moderate to severe asthma, they represent state-of-the-art
maintenance asthma treatment. What’s the evidence supporting them? If you have asthma beyond mild, that is, you’re on a good, low-dose
treatment with inhaled steroid and your asthma
is not optimally controlled, adding a long-acting bronchodilator is a
very effective way to improve symptoms, and over the longer term,
achieve good asthma control with less inhaled steroid delivery. So, improved lung function,
improved night-time sleepiness, reduced exacerbations
is what we want for patients. You can’t use long-acting by themselves? Absolutely not. Clear, unequivocal evidence that, just adding long-acting bronchodilator
to Ventolin without inhaled steroids is deleterious for asthma
and should never be done. We’re essentially talking about
two preparations in Australia. In the Australian context,
we have two preparations. There’s the salmeterol/fluticasone
combination marketed as Seretide. In addition,
we have budesonide/formoterol, marketed as Symbicort. Both with similar effectiveness? They are similarly effective when used
as maintenance treatment for asthma, but as we’ll discuss, formoterol, the long-acting bronchodilator component
of Symbicort, is different from salmeterol, inasmuch as it acts as quickly as
a bronchodilator as salbutamol would. It gives us the opportunity to use that
intermittently for symptom relief as well as maintenance. There are suggestions we’re overusing
combination therapy in Australia. We certainly have overused
inhaled steroids. NORMAN: Meaning, too high a dose? Yeah. One thing is too many patients –
different discussion. Certainly you would have predicted, with the wide use
of long-acting bronchodilator, their inhaled-steroid doses
would have gone down, and they disappointingly
have not gone down much, if at all. We haven’t got that modern political
parlance – efficiency dividend. We have been through a phase
of using too much inhaled steroids. We need to change that. We also need to define a correct patient
to use these very good treatments on, and other patients, for whom lesser
treatments would be as effective. And we have to make sure
the patient has got asthma before we fire these things at them. What would be the metric a GP could use
for him or herself to know whether the right proportion
of his or her patients are on combination therapy? A GP serving a rural community, there will be some patients they don’t
know have asthma. That’s the reality. Some patients will have intermittent
wheeze. They’re a small number. You would estimate that 30% to 40%
of asthmatic patients should be controlled on inhaled steroids
alone. NORMAN: They’ll be mild. Mild by definition. My definition
of mild is, give them inhaled steroid and everybody’s happy
with asthma control. If you give them inhaled steroid
and they’re not well controlled, they go beyond mild.
That’s where combinations kick in. If just under half of your patients
are not on inhaled corticosteroids and most of your patients are
on combination therapy, you’re spreading combination therapy
too much? On reflection, some of those patients
could be as well controlled just with inhaled steroids. And save taxpayers’ money. Save everybody. We have to be efficient across the disease-diagnosis
and drug-treatment spectrum. What’s your percentage, Clive?
Are you doing the right thing? My demographic is different
to what Matthew sees. I work in a rural practice
outside of Ipswich. A large proportion of my patients
are rural. Many of my patients are not as ill
as the patient Matthew sees. NORMAN:
So you’d have a higher proportion just on inhaled corticosteroids? A little higher,
probably about 40%, maybe. A lot of patients are just on
beta-2 agonists by themselves. An increasing proportion
are on combination therapy. That’s the real measure for yourself. It should not be the majority of your
practice on combination therapy. I would agree.
However, I really believe that combination therapy
has made a huge difference to the management of asthma. It’s not that long ago
that I graduated – 1989. From 1989 to now,
the number of people presenting and lying around emergency departments
with that nebuliser going and getting cortisone
squirted into them, that number has dropped hugely,
even in general practice. It’s rare that we see severe
exacerbations presenting at the surgery. Some 15 years ago, we saw a lot more. That’s largely a credit to good drugs,
with good inhaler devices and combination therapy
that’s made a big difference. What’s your impression, Judi? Certainly, there’s not the same
presentations at general practice or in hospitals or emergency visits
from people with asthma. But if we read the more recent reports, the Australian Centre
for Asthma Monitoring report, we’ve still got a long way to ensure
that patients are managed appropriately. A lot of patients could perhaps
be managed better. – So, both overtreated and undertreated.
JUDI: Both. Do we still have an issue
about getting the diagnosis right? You can’t begin to treat any disease without having taken a good history,
then performed a relevant examination. We should try as much as possible
to prove asthma physiologically, and to prove to ourselves
and our patients that the symptoms they’re troubled by
are asthma symptoms, particularly when you’re getting to
second-line treatment. That is – I’ve got a diagnosis,
I’ve given something, it hasn’t worked. So, before you think about combination
therapy, get the diagnosis right. Clive and Judi are right – we’ve got a
spectrum of very good asthma treatments. If you walked back 30 years
with these treatments, you would have been considered
a miracle worker. They’re so effective
compared with the late ’60s, when we had people on 20mg of prednisone
just to keep them out of the hospital. This is a revolutionary change.
Very effective treatments. When very effective treatments
don’t work, we need to go back
into our system of diagnosis. So, spirometry on every patient? Spirometry, sure. That’s one thing.
That’s at a diagnostic level. But systems of diagnosis, of care… The things that Judi and Clive were
saying about reduction in exacerbations, yes, we’ve got better drugs,
but in this country, we’ve been leading the world, perhaps
only matched by the Canadians, in having a comprehensive system of care
and public education. Systems of care for people with asthma
have improved so much. The drugs are good
and the systems of care are better. Often the first step is the pharmacist. Do you feel pharmacists are engaged
in this enough, Stephen? I think they are. An issue I see is,
we do spend a lot of time with the short-acting beta agonists
as pharmacists. We’re the gatekeepers of it
to the majority of the population. A lot of that time
we could add to helping people on inhaled corticosteroids as well,
and combination therapy. There are still people getting
their prescription, their five repeats, potentially not taking it regularly,
twice a day, which is most effective, potentially still on a high dose
that they don’t need to be. They could potentially be
withdrawn down. We really need to look at
these patients, at our script records, and saying, ‘This person hasn’t come in
for a couple of months on prescription. What are they doing with it?
Is there an issue with it? Is it a cost issue, are you worried
about the high dose of steroids?’ All these things can be looked at. And there is considerable out-of-pocket. $31 a month is a considerable amount. NORMAN: Plus your Ventolin. Plus your short-acting beta agonist
as well. We’ve got three or four case studies. I’ve lost sight of how many we’ve got, but stick with us
and we’ll give you them all. Our first case study is Adam,
who’s nine. He’s very active –
plays football, cricket and swims three or four times a week. He was diagnosed a while ago
with mild asthma, and since he was about six,
he’s been trucking along at two or three episodes
of wheezing a month. He manages his symptoms
quite well with salbutamol. In the last couple of months,
he’s noticed an increase in symptoms, and seems to get wheezy
almost every day. Clive, he’s your patient. Adam’s interesting, in that, you can see he’s been exacerbating
for the last two months, where his asthma’s been getting worse. We need to ask ourselves
a few questions. Firstly, has he got asthma?
We’ve decided, yes, he probably does. NORMAN: How have you decided that?
Because he’s got a bit of wheezing? He’s nine,
so he should tolerate a spirometry. He should give us
reasonable flow curves. His history over the past few years, where he has responded well
to salbutamol, is strongly suggestive. It doesn’t mention whether he’s atopic
in any way. We need to establish how much inroad
is asthma making to his life. Is he able to exercise, how much
does he cough, does he wheeze, is he short of breath,
is he waking up at night or is he just somebody who is very aware
of even remote breathlessness? We need to establish
just how severe his asthma is. Once we understand that, we need
to look at how he’s using medication. Is his technique alright,
is he using spacer devices? If he’s doing all of that,
we’ve got to look further and say, ‘How better can we manage him?’ NORMAN: How bettercanyou manage him? He’s nine, so, as he stands, he needs
to be on a decent anti-inflammatory. An inhaled corticosteroid
would be a good choice. But hold on – in the bad old days, you would have said, no inhaled
corticosteroids as first-line, you should go for cromoglycate. It avoids stunted growth,
cataracts later in life. Why not? Let’s look at some of the arguments.
There is still a strong steroid phobia. There are options. Cromoglycate is an
option that’s probably worth looking at. There’s also
leukotriene receptor antagonists. That’s another possibility. Current best treatment is actually
inhaled corticosteroids – low doses delivered to the right place
with a spacer device. They’re good medications. NORMAN: What would you start him on? Something like budesonide
or fluticasone, initially starting him on either 50mcg
or 100mcg twice a day as a starting point, and keeping him
on an asthma-symptoms diary, where we look at his symptoms
and his beta-2 agonist use. Often that’s very empowering – get him involved in the management
of his own disease. We’ve got a chance of at least
finding out better how he’s responding. How long would you wait for an effect
of the corticosteroid? A reasonable period is three weeks. With asthma being a dangerous disease –
people still die from it – you need to keep an open door. If there’s any worsening, there has
to be an asthma action plan in place that he would either present to you
or the hospital, or get hold of further medical advice. What do you think, Judi? Certainly engaging the parents
in the discussion about medication and device use, ensuring there’s an appropriate device
for the child. Nine years old – the parents
should be keeping a close tab on what’s going on at home
as far as medications. It concerns me when a child that age
can’t play sport without symptoms. You’d want to be very sure, and differentiate between normal
huff and puff and true asthma – how long does it take for the symptoms
to resolve after sport, and response to treatment. The Blue Mountains Eye Study,
albeit these are people over 65, has shown that the risk of cataract is
significant on inhaled corticosteroids. Shouldn’t we still be careful about
inhaled corticosteroids, starting them in a child? At this stage, we’ve only got
25, 30 years of experience using inhaled steroids. We’re talking about Adam at nine, unless we get a major
therapeutic advance, having 60, 70 or 80 years
of these drugs. The obligation is
to make the right diagnosis, use the right treatment
on the right patients and to work towards using
the minimal effective dose that achieves the aims of treatment. I have a pragmatic approach
as I talk to patients. I liken it to a Mars bar – ‘A Mars a day
helps you work, rest and play.’ Work is not an issue for Adam,
but he doesn’t miss school, doesn’t have night-time disruption
from cough or wheeze and he’s able to participate in sport
without being restricted by asthma. If we achieve those goals of treatment with the lowest dose of inhaled steroid
possible, we will have done everything
to minimise those risks, and indeed ones we don’t know about yet. Is there still an argument for –
aim high, back-titrate? Is there evidence supporting that, or you should go in with what you think
is the right dose for him and just stick with that? There’s strong evidence that
you end up at the same place, you’ve just followed
two different routes. NORMAN: So start low? Low-edge up or high-edge down,
you end up at the same place. We have to have faith in ourselves. If we start high, come down,
that’s what we have to do. Unfortunately, in Australia, we’ve developed a tradition
of starting high and not going down. NORMAN: And staying high. That’s where people get into problems. What are the statistics on adherence,
Matthew? We know that adherence
is not what we would like it to be. There’s all sorts of reasons. People living with asthma
love to adjust their treatment in accordance with the broad patterns
of their asthma. We know when they feel well,
they drop off their treatment a bit. They get unwell and pump it up again.
That’s one issue. Steroid-phobia has been alluded to,
and we have to acknowledge that. Finally, interesting data from the
Australian Centre for Asthma Monitoring, something we as doctors and other
clinicians working with asthma need to be mindful of – economics do
come into treatment adherence, even in a wealthy country
like Australia. NORMAN: Some people can’t afford it. And there is greater adherence
to asthma treatments in those who are concessionary
beneficiaries on the PBS versus those that are paying full price. We acknowledge hardship
in the community. People are making choices, and some
of those involve not taking treatment. You can’t compel someone to spend money
they don’t have, but at least you’ve got to be mindful
of that in clinical practice, when you’re determining why
someone hasn’t got better. A question coming in from a general
practitioner in New South Wales – ‘To what extent is tapering
of oral steroids necessary when they’ve only been used
for a few days?’ Say, ten days. Most people who have acute asthma should not be on oral steroids
long enough to worry about tapering. In kids, you’re using it
for two or three days – no taper. Most adults are better
in five to seven days, no taper. Even if you’re getting up to
10 to 14 days, you don’t really need to taper. And tapering is very complex.
Remember those historical things – two days on 40, one on 37.5, one on 25, and you’ve got 25mg tablets,
5mg tablets. It takes ten minutes for the
poor pharmacist to dispense them all. I’d just go in 25mg tablets.
Take a full one or half a one. Make it nice and simple. Normal people out there are – ‘Ah…’ (Speaks indistinctly) MATTHEW: Well, different, yeah. Clive, what are the indications? To summarise where we are now,
from what I’ve heard – most people in your practice
have mild asthma, therefore you should not have
most patients on combination therapy. Inhaled corticosteroids
are the first-line therapy when you’ve got somebody
who’s getting frequent asthma. Then the question is,
who gets combination therapy? By definition, the PBS states that
moderate-persistent asthmatics who are not adequately controlled on
a good dose of inhaled corticosteroids – they don’t state exactly how much – those patients are good candidates
for combination therapy. Once we’ve established that,
and fortunately in general practice, even though we’re busy, we do have
the luxury of frequent follow-up within the community,
and we’re accessible. Those people, if we’ve established that
those people not only meet the criteria but would benefit, those are
the patients we would consider either to give them
the salmeterol combination or the Symbicort combination. The choice of patient and the regimen
is practitioner-dependent. Who cares about the practitioner?
Isn’t it patient-dependent? That’s a surprising statement. In fairness,
both are excellent products. It’s really your rationale of treatment
and what would suit that patient best. NORMAN: So it’s patient-centred?
– Sure. Stephen, tell us a bit
about these medications. STEPHEN: We’ll start from the beginning. It’s a stepped approach
to asthma management. For intermittent or infrequent asthma, we’re looking at a short-acting beta
agonist only. That’s all they need. Moving on to more persistent asthma, mild-persistent asthma,
as we’ve stated, a low-dose, inhaled corticosteroid
is the best treatment going around. A low dose, we’re looking at 100 to 200
of fluticasone or beclomethasone or 200 to 400 of budesonide. It is a low dose compared to what often
we’re seeing around. That’s for mild asthma. Going on to moderate-persistent asthma, the next step is to add
a long-acting beta agonist. Studies have shown that it’s more
effective than doubling doses of inhaled corticosteroid alone. You’re having less symptoms,
less exacerbations and better lung function. What Clive was talking about –
you’re giving a reasonable dose, and rather than being tempted
to go up to 1,000mcg a day, that’s the time to think about… Add the beta agonist, yeah.
That’s proven to be more effective. There’s two types of that. This is something
we’ll talk about, Clive – you’ve got somebody on uncomfortably
high doses of inhaled corticosteroids, presumably going on
to combination therapy gives you the opportunity
of lowering steroid dose? The principle stands where we’d like to
use as little medication as possible but as much as the patient needs. This definitely gives that option
to lower the doses, which could be handy
with a lot of patients. There’s two options –
the eformoterol-based one or the salmeterol-based one. The salmeterol, while being a better
agonist, takes 15 to 20 minutes to work. We’re only using that
for maintenance therapy. Both we use for maintenance therapy, but the salmeterol only
for maintenance therapy. It’s a twice-daily dosage using
the same inhaled corticosteroid dosage as you were using before,
adding the long-acting beta agonist. Symbicort is a special one. The eformoterol has a one-
to three-minute onset of action as a bronchodilator. It can be used in two different ways – as maintenance therapy,
still the twice-daily dosage, but there’s another way, where you use Symbicort
as the only inhaler you have, so you don’t have
a short-acting beta agonist, and you use it for PRN symptom relief
as well. That’s proven to be effective. I don’t see how that can’t be toxic.
You can’t have it both ways. A long-acting beta agonist,
which fills up your receptor sites, and you’re taking it as a reliever. Surely this is a recipe for danger? No, it doesn’t work out that way. This is one
of the most interesting things about the paradigm of using Symbicort
for both maintenance and reliever. Symbicort comparison
is the easiest one to do. If you compare a group of patients
with moderate asthma who use two Symbicorts,
morning and evening, plus terbutaline – Bricanyl – versus those who use one Symbicort
morning and evening plus extra Symbicort, in the end, the ones using it both
for maintenance and to relieve use 25% less Symbicort overall. Their lung function is just as good,
their symptoms are just as good, and they experience a marked reduction
in both severe exacerbations and the number of days
they take oral steroids. It’s a less-is-more scenario. Have they been followed for toxicity?
We’ve been caught out before. There’s no reason
to worry about toxicity, because they’re using less Symbicort,
less formoterol. With this new paradigm,
they’re actually using less Symbicort. The health economics is a no-brainer –
less drug, better outcome. By allowing patients to use both
maintenance, which is critical, and using their Symbicort
titrating their asthma treatment by this one simple thing, and that is,
when you feel wheezy, use it. That’s not too hard. What it means is that we can self-adjust
treatment for when they really need it. I should add that it’s only the bottom
two strengths of Symbicort. There’s the 100/6 or the 200/6
but not the 400/12. That’s only for adults,
and children over 12 years of age. So it’s off-label if you prescribe it
for under-12-year-olds. If you were to think of
a combination therapy for Adam… The maintenance and reliever therapy,
it wouldn’t be that. NORMAN: Do you often give children
combination therapy? I wouldn’t say often, but I do have
a cross-section of children that do very well on it,
especially the night wakers, many of the exercise-induced asthmatics
who have ongoing, persistent asthma. They do well. I don’t have a huge number of patients,
but in the under-12s, Seretide is a great product. You’ve got concerns about combination
therapy from what you see around. The concern is just appropriate use,
mainly. Also about,
for the patient’s perspective, understanding the roles
of the medication and how they work. I still see there’s confusion out there. Some patients use salmeterol
as a reliever and combination therapy… Sorry. Using salmeterol as a preventer, using their combination therapy
as a reliever. There is still some confusion
about the roles of medication. To engage the patient in
not just providing information, but ensuring they understand
the importance of taking a reliever… NORMAN:
What about appropriate indications? Sometimes I feel concerned when I see the prescription
of combination therapies for viral-induced exacerbations
of asthma symptoms. The patient presents with a viral
infection and has asthma symptoms – wheeze, cough, night waking, et cetera. They’re prescribed combination therapy. That’s of concern. It’s not following
the PBS guidelines, as Clive mentioned. Let’s go back to the situation
where you’re not responding as well to inhaled corticosteroids. Automatic switch to combination therapy,
or have another think? No, automatic switch on. The switch on is,
does the patient have asthma? Are the symptoms concerning the patient,
and therefore me, related to their asthma? Are they adherent to treatment? We have to use our clinical nous
as to issues around adherence. NORMAN: Don’t just accept
it’s a failure of therapy. No, we have to engage patients.
There’s reasons they’re not adhering. We have to have a script
that works for us. I like to ask them –
‘It’s hard to remember treatment. Would you be more likely to forget your
morning, getting the kids off to school, or the evening, when you’re tired? Which are you more likely to forget?’ They say,
‘Sometimes I forget the evening.’ ‘In a normal week,
would you miss two or three?’ ‘Maybe four or five.’ It slowly comes out. You give them non-punitive permission. You give them permission to fess up, and they want to,
and it’s critical they do. We have to have history-taking skills. The other thing is, do they know
how to use the device correctly? Every device can be used correctly, and
every device can be used incorrectly in a plethora of ways.
We’ve all seen that. So diagnosis,
symptoms related to asthma, adherence in all the different things
and are they getting the drug in? Are they well educated? Do they
understand what we’re trying to achieve? Are they measuring their asthma,
if that’s what we want? How do you cope with that
in a busy rural practice, when you’ve got a queue out the door
and round the corner, to actually get that level of education? How do you organise that
in your practice? NAC provides some pretty good
written literature – action plans, symptom charts,
symptom diaries. Those are useful things,
but also spending that time trying to develop a relationship
with that patient over time – every time they come,
checking their lung function, checking their inhaler technique, finding out what’s going on
with their symptoms, and using asthma educators. NORMAN: Even in rural towns?
– Absolutely. To what extent have we got them
around the country? JUDI: They are dotted around Australia. There’s now a national association
for asthma and respiratory educators, which is encouraging for the profession. Having said that, there’s still
difficulty in accessing them. NORMAN: Take us through the action plans
and remind us how they work. Action plans are very useful tools. Something that needs to be considered
prior to even writing up an action plan is understanding – that patients
understand their medications. If you use peak flows
on their action plans, they have to have recorded
their peak flow for about two weeks when they’re well
to ascertain what the patient’s best is. That’s important to mention
prior to using that action plan. It’s not based on a one-off
peak expiratory flow measurement. If you start somebody when they’re sick,
you’ve got to catch up? Exactly, and coming back for review. Written asthma action plans,
the uptake of them in the population, the last study was 23%. A lot of people with asthma
don’t have them. They’re a useful tool in recognising
deterioration of their asthma, and more importantly,
what steps patients can make to manage their asthma at home without having to rush to the doctor. There’s a lot of self-management skills. We’ve got different areas –
when they’re well, not so well and when to seek medical help. There’s a variety of pro formas
available. Some pharmaceutical companies
provide them. The National Asthma Council have them
on their website. There’s picture ones and coloured ones,
also culturally relevant ones for Aboriginal
and Torres Strait communities. More recently, there’s the Symbicort
Maintenance And Reliever Therapy action plan as well. That is an easy tick-box, and provides simple instructions
about how patients can manage asthma when they’re using Symbicort
as a maintenance and reliever therapy. NORMAN: Any comments on the use
of asthma action plans, Matthew? I was one of the key developers
for the Symbicort SMART action plan. I think it’s absolutely brilliant. I think action plans are important. We have proven
in our health care system, as much as we think they’re important,
we haven’t delivered them. So we have a structural problem. We haven’t been able to convince
ourselves and our patients of their merits in a way
that rolls them out. I’m hopeful for the Symbicort
SMART action plan. It’s simple,
it helps practitioners at all levels to give the education
in the action plan. In my experience, it works for patients,
and they’re not threatened by it. This is AstraZeneca’s product, and
they’re sponsors of tonight’s program. Is there no place for Seretide anymore? No, there is a place for Seretide. There’s a place both for Symbicort
as maintenance treatment and for Seretide
as maintenance treatment. Some people will, on a low dose
of Seretide or Symbicort, have abolition of their symptoms,
no reliever use, no exacerbations. Don’t worry, these are great treatments.
Walk back 30 years, everyone’s laughing. There is a place for it. However, we also recognise there are
people who do have rumbling symptoms, who are at risk of exacerbations, whose symptoms fluctuate from month
to month or year to year, even. That group of moderate and worse asthma
seem to do selectively very well with a product that happens to be
produced by AstraZeneca. This is where the evidence is. Where does the treatment
of allergic rhinitis fit in? Some people would say that
people who have rumbling asthma actually have undertreated
allergic rhinitis, and if you treat that,
you can get away from reliever need. There are two very good reasons
for treating allergic rhinitis. One is, it’s an unrecognised, perhaps
unacknowledged cause of morbidity. It really does compromise quality of
life, having severe allergic rhinitis. Secondly, and possibly because
the lymphocyte pool recirculates between sinus and chest, improving
allergic rhinitis improves asthma. For both those reasons, having a
structured approach to allergic rhinitis from allergen avoidance
through saline washes through nasal steroids
is very important. That can be started when you’re initiating
inhaled-corticosteroid therapy. We would recognise,
and Clive would know, you’re getting to the last minute
of the time you feel
you can comfortably allocate a patient, and there’s a waiting room
full of patients. Anybody with troublesome asthma,
we would ask about rhinitis, try and identify it on the front foot,
and treating it for all those reasons. I think you’d agree, there’s no better
salesman than a satisfied patient. Patients, when they are feeling better, they’re happy to come back
whenever they need to for follow-up. Once they’re feeling better,
they will be more compliant, will have fewer exacerbations
and will try the things you suggest, like trying to manage
their allergic rhinitis, to get rid of smokers out of their
house, to control dust in environments. It all makes a difference. Let’s go to our next case study. Jan is 35 and a single mother. She has long-standing asthma treated with inhaled corticosteroids. She has never had a treatment plan or action plan – she’s not a patient of Clive’s yet – and has become progressively unwell over the last two months. She was admitted to hospital after suffering her first acute exacerbation. She was given oral steroids, discharged the following day to be followed up by her GP. Doesn’t go back to her GP because she thinks she should have an action plan. She comes to Clive a week later, telling him she hasn’t felt this great
in years. She’s just got a steroid high. I was going to ask –
is she still on a steroid high or is she genuinely better controlled? Jan, like the previous case, on history we’re told she’s exacerbated
gradually over time. Her therapy needs to be looked at again. Is inhaled corticosteroid alone
sufficient for her? I would contend that it’s probably not. NORMAN: What if you found out
she wasn’t taking it? I was about to go into that –
has she been compliant? How is she using the medication? We’ve said these things before,
but we can’t emphasise it enough. Again, can she afford the drugs? She’s a single mum, she’s struggling.
Is it a priority? Is she remembering them? There’s a lot of reasons, and are there other features that may
have caused her to exacerbate? Has she had a respiratory infection? Once we’ve established that, we’ve got to start with
a new asthma plan. We’ve got to say,
‘What would you like to do? How can we help you
control your symptoms better?’ And find something that works for her. NORMAN: Judi? I’m interested to think that
she had been well controlled on inhaled corticosteroids. It’s interesting that over just a period
of a couple of months that she’s declined. I’d want to check her device use
and adherence to medications if over two months, it’s been declining. You just wonder what’s causing that. Something in her life happening. Exactly. There could be
increasing stress in her life, who knows,
she might have moved house, got a pet. There could be a whole range
of other things we need to look at. Is this somebody who needs to be seen
by a respiratory physician? No, the GP who’s interested in asthma with a good structure of care
can do this. The other point I’d want to bring up
is smoking. We’ve talked about it already. I have a line
in the educational sessions that somebody who’s queuing up for
this new way of treating asthma who’s a smoker is in the wrong queue. Smoking makes asthma worse, and smoking compromises the response
to asthma treatment, whether that’s inhaled steroids or oral. Identifying other things that are
making things worse is important. I don’t believe these patients need to
be managed by respiratory physicians. But one important thing
Jan needs to know is that she has the potential
to have a severe asthma attack. She has declared herself at risk. There’s nothing
that predicts future risk more than having had the event in the past. We need to gently remind her
that if things went awry, like adherence,
like getting poor technique, if they go wrong in future,
she’s at risk of another bad event. That’s another reason for having
an appropriate action plan to deal with these things before
they end up with her in hospital, which contradicts my Mars-bar therapy,
because she’s away from work. A question from a general practitioner
in Queensland – ‘When writing an asthma action plan
for a patient, should they double their dose
of combination therapy or inhaled corticosteroids
if their symptoms deteriorate?’ Glenn Rice-McDonald published
a good paper a couple of years ago demonstrating that that was ineffective. That patient would probably be
better off managed on other therapy. Combination therapy
would probably suit them well. But if they’re on combination therapy,
should the action plan say, double it? Judi? You want something quick-acting. Symbicort maintenance-reliever therapy
is quite different. But if they’re on standard
maintenance therapy, the key to deterioration of symptoms
is short-acting beta agonists. Use more of it more frequently. NORMAN: And follow the action plan
about when to go back to your GP? If it’s not lasting the three hours, that’s when they should go back
to the GP. That’s the short-acting beta agonist. Clive, let’s go back to Jan.
What will you do for her treatment-wise, assuming it is an acute exacerbation
of asthma? She’s been taking her medications
reasonably well and she’s motivated. Jan, in the position she finds herself,
with her scenario, a single mum, I think single-inhaler therapy
is really appealing. Putting her on a maintenance dose
of Symbicort, 200mg twice a day,
then using it as reliever therapy. If one looks at the action plan which
the pharmaceutical company hands out to GPs – and if you haven’t got it,
you can get it from AstraZeneca – it is well shown, I think,
that she will do better. The guidelines say,
if you’re using x amount, your action plan, between you and
the patient and the action plan itself, will say,
if you’re using up to ten doses a day, you need to see your doctor,
seek medical advice. By reviewing her in a few weeks,
three weeks is probably a good time, we can either uptitrate or downtitrate
her medication. Matthew? As long as she doesn’t have
major inhaler-technique problems, she does fit the bill. She has symptoms
which are unsatisfactory. She’s on an inhaled steroid. She would have found her way into
any one of a number of studies that explored the efficacy of Symbicort as both maintenance and reliever
treatment, and it outperformed
every other comparator. She’s an excellent patient. I agree – I would use 200/6 twice daily
as needed, and I would definitely use it in conjunction with
a Symbicort SMART action plan, not just because I wrote it but because
everybody should have an action plan, particularly once you’ve had
a bad exacerbation. The action plan has been
externally reviewed and endorsed by
the National Asthma Council. It’s available from
the National Asthma Council website. I’ve been in other countries
and shown it to them internationally. It’s recognised as very useful and
a great thing to come out of Australia. Lots of people’s efforts went into that. Let’s go on to our final case study.
It’s David. David has lived with asthma for most of his adult life. He also has significant heart failure and gastro-oesophageal reflux. His current asthma treatment includes fluticasone, 1,000mcg a day, and salbutamol as required for relief. He’s taking that two or three times a week. Following increasing breathlessness, he switched to eformoterol. Despite increasing doses, he’s showing no improvement. Clive? The way this scenario
has been written… NORMAN: It’s a true story.
– Of course, yes. The first thing that screams at me –
have we got the correct diagnosis? He may have had asthma
for much of his life, but is the reason
for his current exacerbation related not perhaps
to his cardiac failure? Is it not perhaps related to
some other respiratory disease? NORMAN: Or his reflux, presumably. Possibly his reflux could
worsen his bronchospasm. Is he not perhaps on new drugs,
like a beta-blocker? Is he using his asthma medication
either correctly, or using it at all? That begs a whole lot of questions. We need to get a better history
and have a good look at him. If he is on a beta-blocker,
I thought it was a mythology that GPs have been too nervous about putting patients on beta-blockers
for cardiac failure, and it’s a life-saving drug? If we go away from asthma to COPD
to start with, there should be limited concerns
about using beta-blockers in people with heart failure and COPD, because the heart failure benefits
are so profound. That said, heart failure studies
systematically excluded people with asthma. So we don’t have information
about people who get pronounced bronchoconstriction
in response to beta-blockers, whether they’re tablets
or even timolol eye drops, which can do the same thing. If you have spectacular
bronchoconstriction with beta-blocker, unfortunately,
we have to go to less than ideal current heart failure treatment. When you see an abrupt change
in apparently stable asthma, all sorts of things, including drugs,
need to be considered. There’s no halfway point,
as in, a small effect to beta-blockers. We see these people from time to time. Beta-blocker-induced airway narrowing
is a very interesting symptom. Where I’ve seen most problems is not in people who have had
lifelong recognised asthma. They must just be peculiarly requiring
their adrenergic systems to keep their airways patent. It hasn’t been the guy
who’s had lifelong asthma, who then got heart failure
and got wheezy on a beta-blocker. Do you do provocation tests
with beta-blockers in it? No. Sorry – yes, I do. What we tend to do is – high-risk patient, heart failure,
stabilising in hospital. Give them a short-acting beta-blocker and monitor their lung function
for a few hours. If they tolerate, they can go on to
standard, twice-a-day treatment. Can you get somebody where,
it is the beta-blocker but after they’ve been
on the beta-blocker for a while? It doesn’t come on at the beginning
of beta-blocker therapy, but during it, and it is the beta-blocker? The ones I’m concerned about,
it’s pretty obvious. It happens quickly,
and it’s reasonably clear observation. Disentangling this person
with breathlessness must be hard. Breathlessness is a wonderful symptom. NORMAN: It keeps respiratory physicians’
meat on the table for life. What do you need to exercise?
We need a structure. You need hearts that pump more blood,
lungs that move more air. Air in the blood
needs to meet in the lungs. We need enough haemoglobin
to carry it around, strong muscles to do the task,
the task can’t be overly heavy and we need to respond in terms of brain
responses to the symptoms of exercise. Any of those things going wrong will
lead to the symptom of breathlessness. Here, is it heart failure?
Has he gained weight? Has he had a sequence of illnesses
that have led to deconditioning and he’s now unfit and wants to go back
to what he used to do, or is it asthma? The important thing
about knowing if it’s asthma is that we have new avenues
of treating him. If we get his airway function better,
his heart failure will improve. If you jump to that assumption too
early, you’re asking for disappointment. We’re selling the guy short. Some of the complex care items that have
been rolled out in general practice, this is a perfect case
where integrated care at all levels, with all clinicians involved, is critical to improve the outcomes
of patients like this. By way of a promo, the National Asthma
Council Australia’s next program for the Rural Health Education
Foundation will be on breathlessness
in the older adult – is it asthma? That will be on in September
of this year. What are your takeaway messages
for people watching, Judi? One of the things for patients and health practitioners
is to work together. It’s a team approach to care,
a chronic condition. It requires ongoing review,
especially when the patient is well, to ascertain whether they are
on the appropriate medication and still maintaining good control. One of the other key things
is device use – ensuring patients
are using their devices correctly. We’ve all talked about that
this evening. Using their device correctly,
and having it checked regularly. Not just asking the patient
how they’re going with their device, but getting them to show you
how they use it. NORMAN: How do you know
the GP knows how to use it? Very good point. It’s a challenge to all of us as health professionals working with
patients with respiratory conditions to make an effort to learn, and follow
the manufacturer’s instructions and gain information. Pharmacists are a wonderful ally. They’re the first port of call
when patients get medications. There’s a lot of training for
pharmacists in asthma management. We’re seeing that through the NAC
A-Team education programs. We’re getting a lot of pharmacists
attending those to update. NORMAN: Stephen, takeaway message? Exactly. Anyone who walks out
of a pharmacy with an inhaler and hasn’t had instruction,
the pharmacist hasn’t done their job. There’s always time to give someone
with an inhaler instruction, otherwise you’re sending somebody away
with expensive medication and no instructions,
and they will get it wrong. Take-home message –
let’s have a look at inhaled steroids and long-acting beta agonists
in combination therapy. Let’s look at dispensing records
and find out how people are taking it. Let’s talk to people about when they’re
taking it, how often they’re taking it and issues surrounding that. So, stepwise approach –
don’t jump to combination therapy. So we can get compliance and adherence
and some of these other issues that are more important
before you jump to a higher dose. NORMAN: Clive? Keeping it simple. We need to get our patients involved and responsible for
their own management, empowering them with the fact
that they can be well controlled. Simple methods – getting them to do
the simple things properly. Also, follow-up – finding out that
the patient is maintaining control. If they’re not, we need to
adjust their medication appropriately. Matthew? Clinicians should be confident to just
use inhaled steroids in mild asthma. When they’re getting moderate
or severe asthma, use a combination treatment. If you haven’t experimented in your
patients with the use of Symbicort as maintenance and reliever, have a go,
have a look at the action plan. If you’re one
who’s abandoned action plans as too complicated, try it again. I think you’ll find it’s a good way
to improve outcomes for patients who have significant, ongoing needs. Thank you all. I hope you’ve
enjoyed tonight’s program. If you’re interested in obtaining more
information about issues raised, there are resources on the Rural Health
Education Foundation’s website. That, as always, is at: Don’t forget to complete and send in
your evaluation forms, and please register for CPD points
by completing the attendance sheet. Thanks to the National Asthma Council
for making the program possible, and to AstraZeneca, who funded the program
through an untied educational grant. And to you, for taking the time
to attend and contribute. I’m Norman Swan. Bye for now. Captions by
Captioning & Subtitling International Funded by the Australian Government
Department of Families, Housing, Community Services
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