Stormy debate over thunderstorm asthma

Clinicians are debating whether to suggest seasonal preventative corticosteroids for people who have mild asthma plus hay fever in new guidelines for thunderstorm asthma prevention in Victoria.

But some are concerned the guidance may be misinterpreted, leading to patient confusion and poor medicine adherence.

Nine people died and thousands suffered breathing problems in the “thunderstorm asthma” event in Melbourne last November, the product of a severe storm combined with an extreme pollen count.

Almost all affected had seasonal hay fever and about a third had undiagnosed asthma, according to the National Asthma Council.

Since then the Victorian government has been working on measures to prepare for a repeat event, with work including a real-time monitoring system for emergency department presentations, an expanded pollen monitoring network and public health campaigns.

And a working group of respiratory clinicians and researchers has been debating how clinical decision-making in Victoria could be tweaked.

Professor Jo Douglass, a respiratory physician and head of the department of clinical immunology and allergy at the Royal Melbourne Hospital, said the group is reviewing protocols and guidelines for treating asthma in Victoria.

She said one option under consideration is to amend the asthma treatment guidelines for Victorians with “mild” asthma – those who have less than two attacks in a month and who have hay fever (seasonal rhino-conjunctivitis) – to recommend preventative medication as well as asthma reliever medication, at least over the spring period.

Guidelines for asthma management in primary care are laid out in the Australian Asthma Handbook, produced by the National Asthma Council Australia.

Professor Douglass said under these guidelines those with intermittent asthma may not require preventative treatment.

“But this asthma epidemic has made clinicians question the wisdom of that, especially in patients with hay fever,  and so that is one of the things being discussed.”

“One doesn’t want to over-prescribe, on the other hand one does want to make sure people at risk are kept safe.”

The idea is still being debated, there are nuances that need to be taken into account, she said.

“Inhaled cortico-steroids are quite safe in modest doses for adults, but high doses in children are potentially a concern – you would have to use clinical discernment.”

Dr Douglass said there was no evidence that the use of inhaled corticosteroids prevented cases of thunderstorm asthma – but this was probably explained by the fact there is little prospective research into the phenomena.

But their use to prevent asthma exacerbations and asthma death is very well reported, so this suggests the strategy highly likely to be beneficial, she said.

National Asthma Council Australia CEO Siobhan Brophy said the council had been involved in the debate, and had some concerns about the proposal.

The handbook’s guidelines already suggest preventative corticosteroids should be taken all year around for most adults with asthma, but in certain circumstances should be only used on a seasonal basis, she said.

But the council has steered away from heavily emphasising the “seasonal-use only” message, in case it confused patients and led to people who should be taking year-round preventative medication only taking it seasonally.

Ms Brophy said the finalised guidelines will be published in a stand-alone paper in the next two weeks and eventually go into an updated version Australian Asthma Handbook, and be replicated in information put out by the Victorian health department.

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