Beasley Et Al 2017 Respirology

EDITORIAL
Asthma prescribing: Where are we headed?

Key words: asthma, prescribing, triple therapy. extensive use of ICS/LABA combination therapy in
Australia, this has not led to better asthma outcomes:
The stepwise approach to the management of asthma Asthma Control Test scores, the proportion of patients
in adults, in which treatment is stepped up to obtain reporting urgent asthma visits and the proportion who
asthma symptom control and reduce the risk of exacer- had hospital or emergency department (ED) visits due
bations and stepped down after a period of sustained to their asthma were similar in the two countries.
control, is enshrined in national1,2 and international3 Should we be surprised by these findings? Probably
guidelines. There is a sound evidence base for this not. In patients with mild or moderate asthma, who
approach, but there are a number of inherent risks that make up the majority of asthmatic population, the
may result in many patients being overtreated. combination of ICS and LABA does not reduce the risk
The first is that the level at which patients are identi- of exacerbations over that achieved with a similar dose
fied as being not under good control (one or more of of ICS alone.9
the following over the previous 4 weeks: daytime symp- So where are we headed? We now recognize that
toms >2 days/week, need for reliever >2 days/week, most adults with asthma have some features consid-
any limitation of activities or any symptoms during the ered characteristic of COPD10 and vice versa,11 which
night or on waking) is set so low that many patients has led to the proposed, but controversial, asthma–
may receive an unnecessary step up in treatment in an COPD overlap syndrome (ACOS).12 Also, international
attempt to achieve good control. Over time, this asthma3 and COPD13 guidelines now recommend that
approach will result in most patients with asthma treatment should be escalated to ‘triple therapy’ with
receiving inhaled corticosteroid (ICS)/long-acting beta maintenance ICS, LABA and long-acting muscarinic
agonist (LABA) therapy, regardless of the initial treat- antagonist (LAMA) therapy if necessary to achieve
ment requirements.4 symptom control and reduce the risk of exacerbations.
The second is that the ICS doses which achieve at This current scenario has the risk that patients with air-
least 80–90% of the maximum therapeutic benefit have way disease (including asthma, COPD and ACOS) will
been called ‘low’ doses,5 and that two additional dose be prescribed ‘triple therapy’ as the default position,
levels of ‘moderate’ (up to twofold higher) and ‘high’ similar to the current prescription of ICS/LABA as the
(over twofold higher) doses are recommended above default treatment for adult asthma in Australia. This
this level.1,3 This terminology encourages the prescrip- potential ‘one size fits all’ approach to the management
tion of higher doses of ICS and ICS/LABA combina- of airway disease may be practical, simple and ‘a safe
tions than are necessary, increasing the risk for adverse bet’ in terms of efficacy, but is surely not in the best
effects for little or no additional benefit.6 interest of patients or government funding agencies,
The third risk is that patients with asthma may have and is contrary to the precision medicine approach
respiratory symptoms that are not due to asthma. which has been pioneered in Australia.14 The medical
Although the full guidelines recognize this, a simplistic profession in New Zealand and Australia (and interna-
approach to stepwise management is likely to result in tionally) needs to work with regulatory authorities,
an unnecessary increase in asthma treatment in patients guidelines groups, not-for-profit non-government orga-
whose symptoms are not primarily due to their asthma, nizations and the pharmaceutical industry to ensure
rather than a focus on the real cause of these symptoms. that triple therapy does not become the default posi-
This has led to the concept of ‘treatable traits’ in which tion for patients with airway disease.
the potential role of endotypes, overlapping disorders,
co-morbidities, environmental and lifestyle factors con- Richard Beasley,1 Jo Hardy1 and Robert Hancox2
1
tributing to respiratory symptoms are considered in all Medical Research Institute of New Zealand, Wellington;
2
patients, and investigated and treated accordingly.7 Department of Preventive and Social Medicine,
These potential risks come into focus with the publi- University of Otago, Dunedin, New Zealand
cation in Respirology of a web-based survey of medica-
tion use, asthma control and healthcare utilization in
Australia and New Zealand.8 These countries have a Acknowledgement
similar asthma prevalence, universal public health ser- The Medical Research Institute of New Zealand is supported by
vices and well-educated general practice and specialist the Health Research Council of New Zealand, Independent
Research Organisation funding.
workforces. However, a key difference is that access to
subsidized ICS/LABA medications has been more
tightly restricted in New Zealand. The main finding of Disclosure statement
the survey is that 82% of ICS users in Australia were R.B. has received payment for lectures from and been a member
prescribed ICS/LABA combination therapy compared of the AstraZeneca, GlaxoSmithKline and Novartis advisory
with only 44% in New Zealand. Despite the more boards, and received research grants from AstraZeneca,
© 2017 Asian Pacific Society of Respirology Respirology (2017) 22, 1487–1488

doi: 10.1111/resp.13159
1488 Editorial
Cephalon, Chiesi, Genentech, GlaxoSmithKline and Novartis. R.- 7 Agusti A, Bel E, Thomas M, Vogelmeier C, Brusselle G, Holgate S,
H. has received payment to his institution for lectures and/or Humbert M, Jones P, Gibson PG, Vestbo J et al. Treatable traits:
advisory boards from AstraZeneca, GlaxoSmithKline and Novar- toward precision medicine of chronic airway diseases. Eur.
tis, and non-financial support from Boehringer Ingelheim. Respir. J. 2016; 47: 410–9.
8 Reddel H, Beckert L, Moran A, Ingham T, Ampon R, Peters M,
Sawyer S. Is higher population-level use of combination ICS/LABA
associated with better asthma outcomes? Cross-sectional surveys
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© 2017 Asian Pacific Society of Respirology Respirology (2017) 22, 1487–1488

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EDITORIAL

Asthma prescribing: Where are we headed?

© 2017 Asian Paciﬁc Society of Respirology Respirology (2017) 22, 1487–1488

© 2017 Asian Paciﬁc Society of Respirology Respirology (2017) 22, 1487–1488

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