ICS/LABA combination dominates Australian asthma treatment

Australians using an inhaled corticosteroid for asthma are almost twice as likely as New Zealanders to take it in combination with a long-acting beta agonist but disease control is equally poor in both countries, new research has shown.

The study from the Woolcock Institute found that 61% of Australians used an ICS-containing inhaler compared to 69% of New Zealanders. The ICS was combined with a LABA in 82% of Australians but only 44% of New Zealanders.

And only 57% of those using an ICS in Australia and New Zealand did so at least five days a week.

Yet Asthma Control Test scores were poor on both sides of the Tasman, with 46% of Australians and 41% of New Zealanders reporting poor asthma control.

The results were derived from a survey of a 3,223 people recruited randomly from a web-based panel.

Speaking to the limbic lead author Professor Helen Reddel said the results were inconsistent with treatment guidelines.

They recommend starting treatment with low-dose ICS and stepping up to an ICS/LABA combination only if asthma remains uncontrolled, after checking inhaler technique and adherence.

PBS listings also require prior treatment with optimal ICS doses before adding a LABA.

“Our findings emphasise the need to carefully individualise treatment for each patient, and aim for the minimum effective dose,” she said.

Professor Reddel said it was important for clinicians to have an empathic conversation with their patients about adherence, and this should include a discussion of cost.

“Most ICS monotherapy can be much more affordable for patients than an ICS/LABA combination, and this may be all that many patients need to keep their asthma well-controlled and at low risk of flare-ups… As doctors we are sometimes unaware of the cost to patients of the medications we prescribe,” she said.

The researchers noted the remarkably rapid uptake of ICS/LABA combinations in Australia. By 2004, only four years after the combination was first PBS-listed, prescribing of the combination by GPs had already outstripped prescribing of ICS-alone inhalers.

Professor Reddel says that GPs may be reluctant to step down asthma treatment when a patient’s asthma is well-controlled, in case their asthma gets worse.

“A more realistic approach to encourage adherence with the guidelines would be to re-emphasise the initiation of treatment with an ICS alone,” she says.

“For example, patients with mild asthma will often achieve good symptom control with one puff of budesonide 400 μg or ciclesonide 160 μg  once a day, and at a much lower monthly cost to them than an ICS/LABA inhaler. Low dose ICS, if taken regularly, halves the risk of serious asthma flare-ups and halves the risk of asthma-related death.”

“Focussing on adherence and inhaler technique is a critical step before increasing the dose or adding another medication.”

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