New guidance is available for GPs on lowering dosages when the condition is well controlled.
Clinicians might need to consider stepping down preventer therapy if a patient’s asthma has been stable for several months, according to researchers from the Woolcock Institute.
In an article published in Australian Prescriber, a team led by Professor Helen Reddel, lead researcher and director of the Australian Centre for Airways Disease Monitoring, provides guidance on reducing the dosage for various medication options, which clinicians can tailor to each patient.
“Most of the benefit of asthma preventer inhalers is seen with low doses,” the authors write. “However, many Australian patients are prescribed doses of inhaled corticosteroids that are higher than necessary to control their asthma.”
The guide is based on findings from a recent study that seven in ten Australians aged 12 and over with asthma are overprescribed asthma medication, as well as a systematic review showing long-term treatment with high doses of inhaled corticosteroids is linked to a small increase in the risks of developing conditions such as cataracts and osteoporosis.
Professor Nick Zwar, chair of the National Asthma Council Australia Guidelines Committee, told TMR that although this issue of overprescription has been around for a few years, getting patients to regularly visit their GPs for consults about their asthma treatment in order to address this issue was an ongoing challenge.
“I think a key issue is helping people with asthma to see [that] it’s something you do need to come back and have a check with your doctor about, even if you don’t have any symptoms,” he said. “[Patients] see it as a problem when they got a cough or wheeze or other symptoms [but] when they feel well, they don’t so much see a need to come to a doctor.
“And the medicines are quite effective, so people might have minimal symptoms and think, ‘well, why would I need to go back?’.
“They might have been started on a higher dose to get their symptoms under control, when in the longer term the dose could be reduced. But that follow up doesn’t always happen.”
Professor Zwar said GPs should be on the lookout for signs of overtreatment among asthma patients, such as oral thrush from ICS or requiring more scripts than should be necessary for their level of asthma. He also emphasised, however, that often the signs aren’t there because patients don’t notice the side effects from overtreatment.
“Usually there’s no adverse effects and people may, in fact, have good asthma control on more medicine than they need to achieve asthma control. So the difficulty is that there may not be [any signs] unless you look at the dose and think about it, and have the opportunity to do that, which is part of the challenge,” he noted.
In their guide, Professor Reddel and co-authors recommend clinicians consult with adult and adolescent patients about lowering the dosage of preventer therapy if the patient’s asthma has been effectively managed by a stable dose of inhaled corticosteroid (ICS) or a combination of corticosteroid and a long-acting beta2 agonist (LABA) for two to three months.
Children’s asthma should be well controlled for six months before lower doses are considered, although authors noted a lack of evidence for the process and benefits in children than in adults and adolescents.
Professor Zwar also warned that evidence supporting the safety and efficacy of combined ICS and LABA medicines in children wasn’t as strong as it is for adults, with more children prescribed these medicines in Australia than in other countries.
“If a child is on a higher dose of inhaled corticosteroid, there is a risk of their growth being slowed down, [which] we would obviously want to avoid. So the [proportion of] kids on high doses of ICS does need to be reviewed,” he said.
In patients with severe asthma, inhaled therapy can carefully be reduced if symptom management and exacerbations align with additional biologic therapy, such as benralizumab or dupilumab, with the priority being eventually ending oral corticosteroid use. Specialists should advise on any dose reduction among this group of patients, the authors wrote.
When discussing stepping down asthma treatment with a patient, clinicians are advised to engage in shared decision making, timing, and assessing any risk factors such as a history of exacerbations. They should also record the patient’s baseline asthma status, gradually adjust doses in small amounts, and instruct them to self-monitor their symptoms and reliever use.
The guide also highlights that clinicians should ensure the patient’s written asthma action plan is up to date and book a follow-up consult a few months after the reduction in treatment to assess symptom management, adherence to the treatment, frequency of use and lung function. If the patient’s asthma remains stable, clinicians should consider further reductions in dose by 25-50%.
In addition to Professor Reddel and co-authors’ advice, Professor Zwar encouraged GPs to consult the Asthma Handbook available on the National Asthma Council website if they have any questions.
“I really hope GPs will use the handbook, and have it as a link on their computer so they can go look at those figures that show the suggested approach to treatment, because it includes dosage advice as well on what is a low, medium and higher dose of medicines.
It was also important to check inhaler technique to make sure the medication was actually being delivered.
More than two million Australians reported living with asthma in the 2021 Census.
