Asthma - steps to control

Published in MedicineWise News

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Overcoming the barriers with updated guidelines | Step 1: Assess asthma symptom control and identify risk factors | Step 2: Treat and adjust to achieve good control | Step 3: Review response and monitor to maintain control | Expert reviewers and references

Key points

  • Consider asthma diagnosis, symptoms and risk factors before treating to achieve control.
  • Initiate or continue inhaled medicines following a review of asthma control.
    • Good control: consider stepping down treatment
    • Poor control: review symptoms related to asthma, check adherence and inhaler technique before stepping up treatment.
  • Review treatment regularly and update written information to aid self-management.

Asthma is one of the most common chronic conditions managed by Australian health professionals.

Overcoming the barriers with updated guidelines

In March 2014 the National Asthma Council launched the Australian Asthma Handbook, replacing the 2006 Asthma Management Handbook. This issue of Medicinewise News reviews key new recommendations in the Australian Asthma Handbook, particularly focusing on adults and adolescents.

Quality use of medicine issues in the management of asthma include:

  • poor adherence to prescribed asthma preventer medicines1
  • poor inhaler technique skills in patients and health professionals2,3
  • missed opportunities to provide written asthma action plans.4

Correction of each of these three issues leads to improved asthma outcomes. For example, provision of a written asthma action plan as part of guided self-management reduces asthma-related mortality and morbidity.5,6

'Asthma affects people of all ages and is associated with a substantial impact on the community ... While there is currently no cure for asthma, there are effective management strategies available to control the disease and prevent the worsening of asthma symptoms.' 4
Australian Asthma Handbook, 2014

Good control is central to ongoing asthma management

The new Australian guidelines emphasise the importance of asthma control as the basis for ongoing treatment decisions and adjustments (Fig 1). Asthma control has two components: first, the patient’s current level of symptom control;A and second, their risk factors for future adverse outcomes such as flare-ups (exacerbations) and adverse effects of treatment.1 Aim to achieve good control in all patients.

Stylised graph showing frail older people display low resilience to minor stressors

Figure 1: Three steps to asthma control.1,7

A. Symptom control over the previous 4 weeks is assessed as good, partial or poor, based on frequency of daytime symptoms, frequency of reliever use (excluding use before exercise), limitation of activities and asthma symptoms during the night or on waking.

Step 1: Assess asthma symptom control and identify the patient’s risk factors

Take the opportunity at every consultation to assess whether the patient has good, partial or poor asthma symptom control, even if asthma was not the primary reason for the visit. This is key to achieving or maintaining good control. The patient’s risk factors for poor outcomes (e.g. flare-up or adverse effects) should also be assessed and managed. At a minimum, ask about flare-ups in the last 12 months, adherence and adverse effects of treatment.

Assess asthma symptom control over the previous 4 weeks

A person with partly controlled or poorly controlled asthma has one or more of the following clinical characteristics:1

  • experiences symptoms more than 2 days a week
  • has asthma symptoms limiting physical activity
  • has symptoms occurring during the night or on waking
  • uses a reliever more than twice a week. B
B. Not including doses taken before exercise. An analysis of PBS data suggests patients have poorly controlled asthma if dispensed 3 or more 200-dose short-acting beta2 agonist (SABA) canisters in 12 months. Consider that some patients will obtain additional SABA relievers over the counter; therefore dispensing history alone cannot be relied upon to assess asthma control.4

Assess the patient’s risk factors

Risk factors for future flare-ups include poor asthma symptom control,8 low lung function (from spirometry),9 having one or more flare-ups in the previous year,9 major psychosocial problems10 and exposure to tobacco smoke.11 When treating adolescents with asthma ensure they know that confidential information, such as whether they smoke, will not be revealed to parents or carers.12

Although asthma medicines have a very good benefit–risk profile, the risk of systemic adverse effects such as developing or advancing diabetes progression is increased with long-term, high-dose inhaled corticosteroids (ICS),13 and prolonged use of oral corticosteroids.7 In addition, failure to rinse, gargle and spit, and to use a spacer after each dose of ICS increases the risk of oropharyngeal effects.2

Only use spirometry if it can be accurately performed

Spirometry in patients with no asthma symptoms at the time of testing cannot exclude an asthma diagnosis,14 as lung function (measured by FEV1 or peak flow) can often be normal in patients with asthma. In addition, a lack of response to a bronchodilator reversibility test does not exclude asthma. Refer patients whose diagnosis is uncertain.1

Asking the same questions to the patient or their carer at each consultation is a useful way to compare asthma control between visits. (e.g. “On average, in the last 4 weeks, how many days a week have you had asthma symptoms? How many nights in the month were you woken by your asthma?”).

Determining if a patient has poorly controlled asthma can be aided by using a quick screening tool to help decide if further detailed assessment is required

The Royal College of Physicians ‘3 questions’ tool consists of three Yes/No questions and has demonstrated reliable assessment of asthma control at 2-weekly intervals in clinical practice settings.15 The Pharmacy Asthma Control Screening tool has five Yes/No questions to answer about the person’s asthma control over the previous month and has been used in community pharmacy settings.16 Avoid switching between any validated control tools such the Asthma Control Test and the Asthma Control Questionnaire or the screening tools mentioned above, as they evaluate different symptoms and so scores are unreliable when making a decision to adjust treatment.17

Exclude factors contributing to poor control before intensifying preventer treatment

Check adherence

Around 50% of people on long-term asthma therapy don’t take their asthma preventer medicines as directed – at least part of the time.7

Ask the patient to show you how they use their inhaler at every consultation, since inhaler technique is often incorrect.

Check inhaler technique

Most children and adults do not use their inhaler correctly, preventing them from receiving the correct dose and maximum benefit from their medicines. This impacts on asthma symptom control and increases the risk of hospitalisation, emergency department visits and patient requirement for antibiotics and oral corticosteroids.18,19

There is a real need for health professionals to regularly ask patients to show them how they use their inhalers, and to be able to demonstrate correct inhaler device use.20 If inhaler technique is checked with a checklist and corrected regularly over time, this can improve clinical outcomes.20

Guidelines recommend that adherence and inhaler technique be assessed at every visit and especially before considering any step-up in treatment.1

Check inhaler device is appropriate

Before prescribing an inhaled medicine, check that the patient is able to use the device. Patients with arthritis may have difficulty using some pressurised metered-dose inhalers (pMDIs) and may need a Haleraid attachment or a breath-actuated inhaler.2,21 Patients with cognitive impairment may have difficulty retaining skills after instruction in the use of an inhaler.2,22 Patients with coexisting chronic obstructive pulmonary disease (COPD) and asthma may not generate sufficient inspiratory flow to use some dry powder inhalers.2,23

For patients prescribed an ICS medicine to be delivered by pMDI, a spacer improves delivery to the lungs and helps reduce the risk of local effects like dysphonia (hoarseness) and oropharyngeal candidiasis.1,24 Mouth rinsing also reduces the chance of candidiasis.24,25 Spacers should be washed in detergent and allowed to air dry without rinsing before using for the first time and then about once a month.1

Consider that symptoms may be due to alternative or comorbid diagnoses

To avoid overtreatment in patients with poorly controlled asthma, consider whether symptoms may be due to a condition other than asthma before stepping up treatment.1 Review the diagnosis of asthma if its basis has not previously been documented in the patient’s notes.1

Investigate any signs and symptoms that suggest an alternative diagnosis or underlying illness (e.g. cough, sputum and frequent chest infections could suggest bronchiectasis; inspiratory wheezing could suggest vocal cord dysfunction).26 The presence of allergic rhinitis is associated with worse asthma control and may require treatment with intranasal corticosteroids.1,27

Asthma is commonly misdiagnosed in adolescents presenting with exercise-related symptoms or cough.28 Conditions in adolescents associated with dyspnoea include hyperventilation, anxiety, lack of fitness, vocal cord dysfunction29 and previously unrecognised congenital heart disease.26

Differentiating between asthma and COPD can sometimes be difficult in older people. Refer to the COPD-X guidelines for further detail on COPD diagnosis.30 Perception of airflow limitation in older people may be affected by acceptance of dyspnoea as ‘normal’ in old age and reduced expectations of activity.30,31

Step 2: Treat and adjust to achieve good control

Australian and international guidelines recommend managing asthma using stepped adjustment to achieve good symptom control and minimise risk of adverse outcomes. Once good asthma control is achieved, the dose can be reduced to find the lowest effective dose of preventer treatment (Fig 2).

Click to expand Achieving optimal control in asthma in adults and adolescents

Figure 2: Achieving optimal control in asthma in adults and adolescents1

All patients should have a reliever inhaler for as-needed use

Every patient with asthma should have a reliever inhaler for quick relief of asthma symptoms. This may be a SABA inhaler, or a low-dose budesonide/eformoterol inhaler for patients prescribed single inhaler budesonide/eformoterol as maintenance and reliever therapy (SMART).1

Most patients can achieve well controlled asthma with low-dose ICS

Patients with symptoms most weeks should be prescribed a regular preventer medicine, to reduce the burden of symptoms and the risk of flare-ups. In adults and adolescents, start preventer treatment with low-dose ICS. If this is taken correctly and regularly, it will lead to good asthma control for most patients, and reduce the risk of hospitalisation and minimise cost.1,32 In children 6–14 years, either low-dose ICS or montelukast can be used as first-line preventer medicine.1

Trial low-dose ICS before ICS/LABA combination therapy

In adults and adolescents not previously taking preventer medicine, ICS alone has a similar benefit to ICS/LABA (long-acting beta2 agonist) with respect to the number of flare-ups requiring oral corticosteroids, hospital admissions and adverse events.33

ICS/LABA combination medicines are often inappropriately prescribed as initial treatment.34,35 This is contrary to Australian and international asthma guidelines, which recommend a stepped approach to treating partly or poorly controlled asthma.1 ICS/LABA combinations can be more expensive to the patient compared with using an ICS alone, potentially influencing adherence to treatment.36

Reserve ICS/LABA as a later option

Guidelines recommend ICS/LABA treatment in favour of increasing the dose of ICS for adults and adolescents whose asthma remains poorly controlled or who have ongoing exacerbations despite using low-dose ICS with good adherence and demonstrating correct inhaler technique.1 When a LABA is needed, combination inhalers are preferred over separate inhalers, as they ensure the patient takes both ICS and LABA components, thereby avoiding the possibility of a LABA being used alone.37 For children, stepping up to medium-dose ICS is preferred over adding a LABA.1

When appropriate, step down treatment

Patients are often very worried about the cost of treatment and the risk of adverse effects. Stepping down asthma medicines can benefit individuals by decreasing adverse effects, treatment burden and costs.38 When considering stepping down:1

  • agree on criteria for identifying worsening asthma control in consultation with the patient and or parent/carer
  • ensure that the patient has an up-to-date written asthma action plan
  • ensure they have enough medicine in their current inhaler so the previous dose can be resumed immediately if asthma control deteriorates
  • schedule a follow-up visit.

Step 3: Review response and monitor to maintain control

Review diagnosis and treatment regularly

Review patients with asthma regularly to optimise their treatment and reduce risk of flare-ups. Asthma treatment course can vary over time, and may differ from patient to patient. If symptoms worsen – despite good adherence and inhaler technique – consider the possibility that they may be due to a comorbid condition or alternative diagnoses and treat modifiable risk factors such as smoking and obesity.1,11,39

Monitor to maintain control

Plan asthma checkups at intervals determined by the individual’s current control and risk factors and record them in the patient’s medical record.1

Written asthma action plans, when combined with self-monitoring of symptoms or peak flow and with regular medical review, help reduce asthma-related mortality and morbidity in adults.5,6 Such action plans also help asthma management in children when there is education on self-evaluation.40 However, despite evidence supporting their use, only about 14% of Australian adults and adolescents with asthma, and fewer than 50% of children with asthma, have a written asthma action plan.4 Written action plans should be reviewed every year, and updated whenever the patient’s asthma treatment changes.

Expert reviewers

Clinical Associate Professor Helen Reddel, Central Clinical School, Woolcock Institute of Medical Research, Sydney

Dr Russell Wiseman, General Practitioner and National Asthma Council and Australian Lung Foundation Committee Member, Queensland

  1. Australian asthma handbook. Melbourne: National Asthma Council Australia, 2014. [Online] (accessed 19 March 2014).
  2. National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. 2008. [Full text] (accessed 2 October 2013).
  3. Basheti IA, Qunaibi E, Bosnic-Anticevich SZ, et al. User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia. Respir Care 2011;56:1916–23. [PubMed]
  4. Australian Centre for Asthma Monitoring. Asthma in Australia 2011. Canberra: Australian Institutes for Health and Welfare, 2011.
  5. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003:CD001117. [PubMed]
  6. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94–9. [PubMed]
  7. Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma, 2012.
  8. Bateman ED, Bousquet J, Busse WW, et al. Stability of asthma control with regular treatment: an analysis of the Gaining Optimal Asthma controL (GOAL) study. Allergy 2008;63:932–8. [PubMed]
  9. Zeiger RS, Yegin A, Simons FE, et al. Evaluation of the National Heart, Lung, and Blood Institute guidelines impairment domain for classifying asthma control and predicting asthma exacerbations. Ann Allergy Asthma Immunol 2012;108:81–7. [PubMed]
  10. Yonas MA, Lange NE, Celedon JC. Psychosocial stress and asthma morbidity. Curr Opin Allergy Clin Immunol 2012;12:202–10. [PubMed]
  11. Thomson NC, Chaudhuri R, Livingston E. Asthma and cigarette smoking. Eur Respir J 2004;24:822–33. [PubMed]
  12. The Royal Australasian College of Physicians. Confidential health care for adolescents and young people (12–24 years). September 2010. [Online] (accessed 26 February 2014).
  13. Suissa S, Kezouh A, Ernst P. Inhaled corticosteroids and the risks of diabetes onset and progression. Am J Med 2010;123:1001–6. [PubMed]
  14. Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. A national clinical guideline. May 2008. Revised January 2012. [Full text]  (accessed 29 January 2014).
  15. Thomas M, Gruffydd-Jones K, Stonham C, et al. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians '3 questions'. Prim Care Respir J 2009;18:83–8. [PubMed]
  16. LeMay KS, Armour CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J 2014;23:79–84. [Online]
  17. Vermeulen F, de Meulder I, Paesmans M, et al. Asthma control measurement using five different questionnaires: a prospective study. Respir Med 2013;107:1314–21. [PubMed]
  18. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930–8. [PubMed]
  19. Chen SH, Yin TJ, Huang JL. An exploration of the skills needed for inhalation therapy in schoolchildren with asthma in Taiwan. Ann Allergy Asthma Immunol 2002;89:311–5. [PubMed]
  20. Basheti IA, Reddel HK, Armour CL, et al. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol 2007;119:1537–8. [PubMed]
  21. Rees J. Methods of delivering drugs. BMJ 2005;331:504–6. [PubMed]
  22. Allen SC, Jain M, Ragab S, et al. Acquisition and short-term retention of inhaler techniques require intact executive function in elderly subjects. Age Ageing 2003;32:299–302. [PubMed]
  23. Broeders ME, Molema J, Hop WC, et al. Inhalation profiles in asthmatics and COPD patients: reproducibility and effect of instruction. J Aerosol Med 2003;16:131–41. [PubMed]
  24. van Asperen P, Mellis CM, Sly PD. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. [Full text] (accessed 4 March 2014).
  25. Yokoyama H, Yamamura Y, Ozeki T, et al. Effects of mouth washing procedures on removal of budesonide inhaled by using Turbuhaler. Yakugaku Zasshi 2007;127:1245–9. [PubMed]
  26. Levy ML, Fletcher M, Price DB, et al. International Primary Care Respiratory Group (IPCRG) Guidelines: diagnosis of respiratory diseases in primary care. Prim Care Respir J 2006;15:20–34. [PubMed]
  27. National Asthma Council Australia. Managing allergic rhinitis in people with asthma. 2012. [Full text] (accessed 26 February 2014).
  28. Towns SJ, van Asperen PP. Diagnosis and management of asthma in adolescents. Clin Respir J 2009;3:69–76. [PubMed]
  29. Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007;120:855–64. [PubMed]
  30. McKenzie D, Abramson M, Crockett A, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease V2.34. C4.1 Confirm or exclude asthma. 2012. [Online] (accessed 12 February 2014).
  31. Global Inititiative for Asthma. A pocket guide for physicians and nurses. 2011. [Full text] (accessed 29 January 2014).
  32. Suissa S, Ernst P, Kezouh A. Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Thorax 2002;57:880–4. [PubMed]
  33. Ni Chroinin M, Greenstone I, Lasserson TJ, et al. Addition of inhaled long-acting beta2-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults and children. Cochrane Database Syst Rev 2009:CD005307. [PubMed]
  34. O'Byrne PM, Reddel HK, Colice GL. Does the current stepwise approach to asthma pharmacotherapy encourage over-treatment? Respirology 2010;15:596–602. [PubMed]
  35. Colice GL, Yu AP, Ivanova JI, et al. Costs and resource use of mild persistent asthma patients initiated on controller therapy. J Asthma 2008;45:293–9. [PubMed]
  36. Hynd A, Roughead EE, Preen DB, et al. The impact of co-payment increases on dispensings of government-subsidised medicines in Australia. Pharmacoepidemiol Drug Saf 2008;17:1091–9. [PubMed]
  37. Worsnop C. Combination inhalers for asthma. Aust Prescr 2005;28:26–8. [Online]
  38. Heiner MM. Key barriers to optimal management of adult asthma in Australia: physician and patient perspectives. Curr Med Res Opin 2007;23:1799–807. [PubMed]
  39. Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med 2007;175:661–6. [PubMed]
  40. Agrawal SK, Singh M, Mathew JL, et al. Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial. Acta Paediatr 2005;94:1742–6. [PubMed]