Treatment Steps for Chronic Persistent Asthma in SA

Question 1

What must be the mainstay of asthma treatment unless there is a compelling reason to the contrary?

Answer 1

Inhaled corticosteroid must be mainstay of treatment

• most effective
• least SE

Question 2

What is the only compelling reason to not use ICS as a mainstay of asthma therapy?

Answer 2

Allergic reaction

- then can change to leukotriene modifier

Question 3

Level 1 Asthma: what treatment should be used?

Answer 3

Short-acting beta-2 agonist as required

only for mild, intermittent asthma

Question 4

Level 2 Asthma: what treatment should be used?

Answer 4

1. Low dose ICS

2. Short acting beta-2 agonist as required for acute symptom relief

Question 5

Level 3 Asthma: what treatment should be used?

Answer 5

1. Low dose ICS
2. Long acting beta-2 agonist
   OR
   Leukotriene modifier
3. Short acting beta-2 agonist as required for acute symptom relief

Question 6

Level 4 Asthma: what treatment should be used?

Answer 6

1. Moderate dose ICS
2. Long acting beta-2 agonist
   OR
   Leukotriene modifier
   OR
   SR Theophylline
3. Short acting beta-2 agonist as required for acute symptom relief

Question 7

Level 5 Asthma: what treatment should be used?

Answer 7

1. High dose ICS
2. Long acting beta-2 agonist
   +/-
   Leukotriene modifier
   +/-
   SR Theophylline
3. Short acting beta-2 agonist as required for acute symptom relief

Question 8

Level 6 Asthma: what treatment should be used?

Answer 8

1. High dose ICS
2. Long acting beta-2 agonist
   +/-
   Leukotriene modifier
   +/-
   SR Theophylline
   +/-
   Oral Corticosteroid
3. Short acting beta-2 agonist as required for acute symptom relief

Question 9

When should specialist referral be considered?

Answer 9

Step 4, refer to pulmonologist!

Consider specialist referral at level 4-6

Question 10

Step 1 in the management of asthma, what is the preferred option?

Answer 10

As needed SABA

Question 11

Step 1 in the management of asthma, what are other recommended options?

Answer 11

Consider low dose ICS in addition to as needed SABA for patients at risk for exacerbations

Question 12

Step 2 in the management of asthma, what is the preferred option?

Answer 12

Low dose ICS, plus as needed SABA

Question 13

Step 2 in the management of asthma, what are other recommended options?

Answer 13

LRTA
Low dose ICS / LABA
ICS started with symptoms of allergic asthma for seasonal treatment only

Question 14

Step 3 in the management of asthma, what is the preferred option?

Answer 14

Low dose ICS / LABA, plus as needed SABA for adults / adolescents

Question 15

Step 3 in the management of asthma, what are other recommended options?

Answer 15

Medium dose ICS for adults / adolescents

Low dose ICS plus LRTA or low dose sustained release theophylline

Question 16

Step 4 in the management of asthma, what is the preferred option?

Answer 16

Medium dose ICS / LABA, plus as needed SABA for adult / adolescents
OR
Medium dose ICS / formoterol as both maintenance and reliever

Question 17

Step 4 in the management of asthma, what are other recommended options?

Answer 17

Add on therapy with Tiotropium for adults with exacerbation history

Question 18

Step 5 in the management of asthma, what is the preferred option?

Answer 18

Refer to specialist and consideration of add on treatment

Question 19

Step 5 in the management of asthma, what are other recommended options?

Answer 19

Tiotropium if <18 years
Omalizumab for moderate to severe allergic asthma
Sputum guided add on low dose OCS (<7.5mg/day prednisone equivalent)

Question 20

What 5 steps should be followed for poor control?

Answer 20

1. Watch patient using their inhaler, discuss adherence barriers to use
2. Confirm the diagnosis of asthma
3. If possible, remove potential risk factors. Assess and manage comorbidities
4. Consider treatment step-up
5. Refer to a specialist or severe asthma clinic

Question 21

What is step 1 for a poorly controlled patient?

Answer 21

1. Watch patient use their inhalers, check against inhaler checklist.
   - show correct method, and recheck up to 3 times
   - repeat check each visit
2. Have empathetic discussion to identify poor adherence
   - ask about beliefs, cost of medications and refill frequency

Question 22

What is step 2 for a poorly controlled patient?

Answer 22

If no evidence of variable airflow limitation on spirometry or other testing consider halving ICS dose and repeating lung function after 2-3 weeks, check patient has action plan.
- consider referring for a challenge test

Question 23

What is step 3 for a poorly controlled patient?

Answer 23

• Check risk factors or inducers such as smoking, beta-blockers or NSAIDs or occupational or domestic allergen exposure
• Check for and manage comorbidities (e.g. rhinitis, obesity, GERD, obstructive sleep apnea, depression / anxiety) that may contribute to symptoms

Question 24

What is step 4 for a poorly controlled patient?

Answer 24

Consider step up to next treatment level or alternative option on present level
- use shared decision making and balance potential benefits and risks

Question 25

What is step 5 for a poorly controlled patient?

Answer 25

If asthma is still uncontrolled after 3-6 months on high dose ICS/LABA, or with ongoing risk factors, refer to a specialist or severe asthma clinic
- refer earlier than 6 months if asthma very severe or difficult to manage or if doubts about diagnosis