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CPD ACTIVITY 59 ASTHMA RELIEVERS: THE NEW PARADIGM Table 1. Anti-inflammatory relievers. Mild asthma An estimated one in nine Australians have asthma, which is around 2.5 million people.1 Most people with asthma (about 70 per cent) have mild asthma.2 However, mild asthma can lead to severe complications and the need for emergency treatment and hospitalisation.3 Between 30 and 40 per cent of exacerbations or flare-ups requiring emergency care are in patients with mild asthma.4 Mild asthma is associated with a significant burden, with many patients experiencing suboptimal symptom control, asthma flare-ups and even death.5 Between 15 and 20 per cent of adults dying from asthma are largely asymptomatic in the preceding three months (ie, have had asthma symptoms less than weekly).16 The goals of therapy for patients with asthma are: • Relieve and control symptoms. • Prevent exacerbations. • Reduce loss of lung function, with minimal adverse effects. Good symptom control of asthma is defined as daytime symptoms ≤2 days per week, need for SABA reliever ≤2 days per week (not including doses taken prophylactically before exercise), no limitation of activities and no symptoms during the night or on waking (Table 2).6 This assessment is based on symptoms over the previous four weeks. 2 CPD CREDITS Debbie Rigby BPharm GradDipClinPharm AdvPracPharm AACPA FPS Debbie is a consultant clinical pharmacist from Brisbane. She graduated with a Bachelor of Pharmacy from the University of Queensland and has a Graduate Diploma in Clinical Pharmacy, Certification in Geriatric Pharmacy and Advanced Diploma in Nutritional Pharmacy among other qualifications. She was the inaugural recipient of the AACP Consultant Pharmacist Award in 2008. Debbie is a director on the NPS MedicineWise board and Chair of the Society of Hospital Pharmacists of Australia Accredited Pharmacist Reference Group. She conducts home medicine reviews in collaboration with GPs in a medical centre, as well as providing education to pharmacists, GPs, nurses, nurse practitioners and consumers. Conflicts of interest: Debbie has accepted honorariums for presentations, advisory groups and travel with AstraZeneca. Product Symbicort Rapihaler 100/3 Symbicort Turbuhaler 200/6 DuoResp Spiromax 200/6 Initial dose 2 inhalations as needed 1 inhalation as needed 1 inhalation as needed Maximum doses per single occasion 12 inhalations 6 inhalations 6 inhalations Maximum total daily dose 16 inhalations 8 inhalations 8 inhalations PBS quantity 2 packs, 2 repeats 1 pack, 2 repeats 1 pack, 2 repeats Age restriction 12 years or over 12 years or over 18 years or over LEARNING OJECTIVES After completing this CPD activity, pharmacists should be able to: • Describe the extent and consequences of over-reliance on short-acting bronchodilators in asthma • Compare outcomes with anti- inflammatory relievers for patients with mild asthma.. • Discuss with patients the benefits of anti-inflammatory reliever therapy for mild asthma. 2016 Competency Standards: 2.2, 3.2, 3.5. Accreditation Number: A2008RP2 (exp: 31/07/2022). The most fundamental change in asthma management in 30 years is happening now. Over-reliance on short-acting beta2- agonists (SABA) relievers for symptomatic management of mild asthma in adults and adolescents is common. Recent evidence from large randomised controlled trials supports the use of as-needed budesonide/formoterol as an alternative to as-needed SABA relievers in patients with mild asthma. From June 2020 budesonide/formoterol is subsidised on the PBS for patients with mild asthma who require anti-inflammatory reliever therapy (Table 1). Short-acting beta2-agonists SABAs including salbutamol and terbutaline relieve symptoms rapidly and provide temporary control of symptoms but have no effect on the underlying inflammation associated with asthma. Terbutaline is PBS subsidised only for patients unable to achieve coordinated use of a metered dose inhaler containing a SABA or have experienced a clinically important product-related adverse event during treatment with another SABA. Salbutamol is available over the counter as a pharmacist-only medication and is subsidised on the PBS. Inhaled corticosteroids (ICS) are the mainstay of asthma management in adults and adolescents and act to reduce the incidence and severity of symptoms, reduce severe exacerbation risk, and reduce airway remodelling due to their anti-inflammatory actions.4 Low-dose ICS reduce severe exacerbations by about 50 per cent in patients with mild asthma, as well as controlling symptoms and improving quality of life.7 The new term ‘anti-inflammatory reliever’ refers to as-needed low-dose ICS in combination with a rapid-onset long-acting beta2-agonist (LABA) in a single inhaler. Formoterol has a rapid onset of action, comparable to SABAs. Budesonide/formoterol can Table 2. Definitions of asthma symptom control in adults and adolescents. TO PAGE 60 Good control Partial control Poor control All of: • Daytime symptoms ≤2 days per week • Need for SABA reliever ≤2 days per week • No limitation of activities • No symptoms during night or on waking One or two of: • Daytime symptoms >2 days per week • Need for SABA reliever >2 days per week • Any limitation of activities • Any symptoms during night or on waking Three or more of: • Daytime symptoms >2 days per week • Need for SABA reliever >2 days per week • Any limitation of activities • Any symptoms during night or on waking RETAIL PHARMACY • AUG 2020