What is the recommended treatment plan for a patient with asthma in Australia, according to the Australian Asthma Handbook?

Australian Asthma Management Guidelines

Initial Treatment Approach

For adults and adolescents with mild asthma in Australia, the updated guidelines now recommend as-needed low-dose budesonide-formoterol combination inhaler as the preferred first-line option, replacing the traditional approach of daily inhaled corticosteroids plus as-needed short-acting beta-agonist. 1

Key Rationale for Updated Recommendations

• Mild asthma is not a benign condition—patients remain at significant risk of severe exacerbations, particularly when overusing short-acting beta-agonists like salbutamol 1
• The budesonide-formoterol combination taken as-needed provides both immediate symptom relief and reduces the risk of severe flare-ups 1
• This approach addresses the common problem of poor adherence to daily controller medications while ensuring anti-inflammatory treatment is delivered when symptoms occur 1

Stepwise Treatment Algorithm

Step 1: Mild Intermittent Asthma

• As-needed low-dose budesonide-formoterol (160/4.5 μg) for patients with occasional symptoms (<2 times/month), no nocturnal symptoms, no exacerbation risk, and FEV1 >80% predicted 2
• Take 1-2 inhalations as needed for symptom relief 2

Step 2: Mild Persistent Asthma

• As-needed low-dose budesonide-formoterol remains the recommended approach, which significantly reduces moderate-to-severe exacerbations compared with short-acting beta-agonist monotherapy 2
• Alternative: Daily low-dose inhaled corticosteroid plus as-needed short-acting beta-agonist 3

Step 3: Moderate Persistent Asthma

• Low-dose inhaled corticosteroid-long-acting beta-agonist (ICS-LABA) combination as maintenance therapy 3, 4
• Alternative: Medium-dose inhaled corticosteroid alone 3
• Continue as-needed reliever therapy 3

Step 4: Moderate-to-Severe Persistent Asthma

• Medium-dose ICS-LABA combination 3, 4
• If uncontrolled, consider triple therapy (ICS-LABA plus long-acting muscarinic antagonist) to improve symptoms, lung function, and reduce exacerbations 3, 2

Step 5: Severe Persistent Asthma

• High-dose ICS-LABA combination 3, 4
• Add biologic therapy for severe type 2 asthma (characterized by elevated blood/sputum eosinophils ≥150/μl, FeNO ≥35 ppb, or elevated total IgE) 2
• Consider low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) only as last resort 2

Essential Diagnostic Confirmation

• Confirm diagnosis with spirometry demonstrating bronchodilator reversibility: FEV1 improvement ≥12% AND ≥200 mL after bronchodilator 3, 4
• When spirometry shows FEV1 ≥70% predicted but asthma is suspected, perform bronchial provocation testing (methacholine challenge) 2
• Measure fractional exhaled nitric oxide (FeNO) to identify type 2 inflammation—FeNO ≥35 ppb suggests eosinophilic inflammation and predicts corticosteroid responsiveness 2
• Perform allergy testing (skin prick or specific IgE) in patients with persistent asthma requiring daily medications to identify relevant allergen triggers 3, 4

Monitoring and Follow-Up Schedule

• Schedule visits every 2-4 weeks after initiating therapy or stepping up treatment 2
• Once control is achieved, schedule visits every 1-3 months depending on severity and stability 2
• Perform spirometry at initial assessment, after treatment initiation, during periods of progressive loss of control, and at least every 1-2 years 3, 4
• Consider daily peak flow monitoring for patients with moderate-to-severe persistent asthma, history of severe exacerbations, or poor perception of airway obstruction 4

Critical Assessment Parameters at Each Visit

• Document daytime symptom frequency (days per week) and nighttime awakenings (nights per month) 3, 4
• Quantify short-acting beta-agonist use—use >2 days/week (excluding exercise prophylaxis) indicates inadequate control requiring step-up therapy 4
• Assess activity limitations and school/work attendance 4
• Review and verify proper inhaler technique at every visit—inadequate technique is a common cause of poor control 3, 2
• Evaluate adherence to prescribed medications 3, 4
• Identify and address environmental trigger exposures (tobacco smoke, house dust mite, cockroach, animal dander, mold) 3

Severe Asthma Definition and Management

Severe asthma is defined as uncontrolled asthma despite 3 or more months of continuous standardized use of medium- or high-dose ICS-LABA, after treating comorbidities and avoiding environmental triggers, or worsening when stepping down to lower dose ICS-LABA. 2

Severe Asthma Treatment Options

• For severe type 2 asthma with good response to biologics, prioritize decreasing or stopping maintenance oral corticosteroids, but never completely stop ICS-LABA maintenance therapy 2
• Add azithromycin 250-500 mg three times weekly for 26-48 weeks in adult patients with persistent symptoms despite step 5 treatment to reduce exacerbations 2
• Consider bronchial thermoplasty for adult patients whose asthma remains uncontrolled despite optimized treatment and specialist referral, or when targeted biologic therapy is unavailable or inappropriate 2

Specialist Referral Indications

• Difficulty achieving or maintaining control despite appropriate therapy 4
• Two or more oral corticosteroid bursts in the past year 4
• Any hospitalization for asthma 4
• Step 4 or higher treatment required 4
• Persistent symptoms despite correct inhalation technique and adherence to step 4 treatment 2
• Consideration of immunotherapy or biologic therapy 4

Written Asthma Action Plan Requirements

• Provide all patients with a written asthma action plan including instructions for daily management, recognizing worsening symptoms, and medication adjustments 3, 4
• Teach patients to recognize when peak expiratory flow drops below 75% of personal best or predicted value, indicating need to increase treatment 5
• Include specific instructions on when to increase inhaled corticosteroids, when to start oral corticosteroids, and when to seek emergency care 3, 4

Common Pitfalls to Avoid

• Do not rely on short-acting beta-agonist monotherapy for mild asthma—this approach fails to address underlying inflammation and increases exacerbation risk 1
• Avoid prescribing antibiotics unless bacterial infection is confirmed—they are overused in asthma exacerbations without evidence of benefit 5, 6
• Never use sedation during acute exacerbations—it is contraindicated and dangerous 5
• Do not use percussive physiotherapy during acute exacerbations—it is unnecessary and unhelpful 5
• Recognize that prolonged high-dose inhaled corticosteroids may cause systemic adverse effects including osteoporosis, hypothalamic-pituitary-adrenal axis suppression, and increased pneumonia risk 2