The National Asthma Council has developed a stepwise treatment algorithm for selecting and adjusting asthma medicines for adults and adolescents.
For all patients:
- assess individual risk factors and comorbidity
- advise/prescribe a reliever to be carried at all times
- provide education
- write a personalised asthma action plan
- provide information on non-pharmacological factors that influence asthma
- ask about the patient’s goals and concerns and involve the patient in making treatment decisions.
Step 1 of this algorithm is for ‘few patients’ who will only require treatment with as-needed SABA alone.
These patients have symptoms less than twice a month and no risk factors for flare-ups. Their SABA use needs to be monitored, and their need for preventer treatment should be continually reassessed.
Step 2 of this algorithm is for ‘most patients’. These patients require treatment with:
Regular daily maintenance ICS (low dose) and also a SABA reliever as needed
Budesonide + formoterol (low-dose) as needed.
This is a suitable starting treatment option for most new patients.
Step 3 of this algorithm is for ‘some patients’. These patients require treatment with:
Regular daily ICS + LABA (low dose)
This option refers to ICS + formoterol as maintenance and reliever therapy (low dose as regular daily maintenance treatment, plus low dose as needed for symptom relief)
Regular daily maintenance ICS+LABA combination (low dose) and also a SABA reliever as needed.
Step 4 of this algorithm is for ‘few patients’. These patients treatment with:
Regular daily ICS+LABA (medium to high dose as regular daily maintenance treatment plus low dose as needed for symptom relief)
Regular daily maintenance ICS+LABA combination (medium to high dose) and also a SABA reliever as needed.
Consider starting at step 3 or 4 for a new patient with frequent or uncontrolled symptoms (check PBS criteria).
For patients at step 4, consider referral. Also consider add-on treatments such as tiotropium. These patients should be monitored and their medicines adjusted to maintain good symptom control and minimise risks at the lowest effective ICS dose.
For patients at step 5, refer to specialist and add-on specialised treatment.
Before you consider stepping up treatment, check that
- symptoms are due to asthma
- inhaler technique is correct
- adherence is adequate.
Consider stepping up if good control is not achieved despite good adherence and correct inhaler technique.
When asthma is stable and well controlled for 2–3 months, consider stepping down treatment.
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