Combined inhaler now on PBS for mild asthma

People with mild asthma now have access to combined budesonide/formoterol treatment, to use as needed, subsidised on the Pharmaceutical Benefits Scheme

People with mild asthma now have access to combined budesonide/formoterol treatment, to use as needed, subsidised on the Pharmaceutical Benefits Scheme.

The inhaled corticosteroid/short-acting beta agonist combination, sold as Symbicort, is recommended by the Global Initiative on Asthma for daily use in moderate to severe patients and as needed for mild patients.

The PBS changes, which take effect today for patients 12 and older, affect only the regimen, not the products (Symbicort Turbuhaler and Rapihaler, which each come in several dosages).

Mild asthma, estimated to affect one million Australians, is responsible for 20% of asthma deaths, according to the National Asthma Council.

Most mild asthma patients rely entirely on the SABA salbutamol – Ventolin, the famous “blue puffer” – alone, which is cheap and familiar and lacks the connotations of steroids.

But GINA – whose science committee is chaired by Professor Helen Reddel of Sydney University’s Woolcock Institute – last year recommended, after more than a decade of research, that bronchodilation alone was insufficient and anti-inflammatory corticosteroids were needed for good control of asthma.

A forthcoming revision of the Australian Asthma Handbook, previewed today, includes a new flow chart on selecting treatments for asthma and when to refer to a specialist.

The PBS listing was an important change, said Professor Peter Wark of Newcastle University, a respiratory specialist at John Hunter Hospital and member of the Australian Asthma Handbook committee.

“The change is all to do with people with mild disease, who may well have very intermittent symptoms and their asthma may not be evident all the time, but it still has the potential to cause serious exacerbations,” he told TMR.

“One in five hospital admissions are in people with mild asthma. We know these individuals often don’t have great adherence to their regular preventers.”

Evidence is growing that SABAs alone may be not only inadequate but dangerous, putting over-reliant users at greater risk of potentially fatal asthma attacks.

“We know that using a bronchodilator alone more than a couple of times a month is associated with increased risk of severe attacks and poorer day-to-day control,” Professor Wark said.

“Less frequent use may well be safe, but for anyone who has symptoms more than a couple of times per month, it’s very clear they should either be using a regular inhaled corticosteroid preventer, or now there’s the option of using inhaled budesonide/formoterol on an as-needed basis.”

NAC CEO Siobhan Brophy said the combination drug was now accessible for people starting treatment and as another option for those who struggle to take a regular daily preventer.

“So now when they’re taking their reliever, they get some of that really important inhaled steroid along with it,” Ms Brophy told TMR.

“It has the potential to facilitate use of that important preventive medication by people who otherwise might only ever rely on the blue reliever.”

She said there were only very few adults and adolescents who could properly control their asthma using just the blue reliever.

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“So we want to get the message out to the other people, and to their prescribers and clinicians, that most people with asthma should be on some sort of regular preventer.”

Ms Brophy said patients on preventer medication had fared much better during the thunderstorm asthma event, last summer’s bushfires and COVID-19.

“Having that good control of the inflammation in your lungs sets you up much better for those unexpected challenges,” she said. “The people who ended up in strife tended to be people who weren’t on a regular preventer.”

“It’s really important to understand that asthma’s a chronic inflammatory disease of the airway,” Professor Wark said. “While symptoms may vary, almost invariably there’s this chronic inflammatory process that’s going on in the background.

“So someone might forget they’ve had two or three puffs of their Ventolin in the past week and not think much of it, but if they get a cold or get caught in a thunderstorm if they’re allergic to grass, or some other event like the bushfires, then they are at risk of developing severe exacerbations.

“[These changes] will allow you to adjust your preventer treatment in association with the symptoms and you can vary that and get those symptoms under control, hopefully preventing you from going on to have to use prednisone or, worse, presenting to hospital.”

A new version of the Written Asthma Action Plan template incorporating Symbicort, written by manufacturer AstraZeneca and endorsed by NAC, is due out this week.

This Saturday, the OPC AIRTIME seminar will feature a special session at 11.20am where three members of the Asthma Guidelines committee – Professor Peter Wark, Professor Amanda Barnard (Chair) and Dr Russell Wiseman – will discuss the implications of the changes announced today. Register for the free webinar HERE.