EDITORIAL
Asthma prescribing: Where are we headed?
Key words: asthma, prescribing, triple therapy.
The stepwise approach to the management of asthma
in adults, in which treatment is stepped up to obtain
asthma symptom control and reduce the risk of exacer-
bations and stepped down after a period of sustained
control, is enshrined in national1,2 and international3
guidelines. There is a sound evidence base for this
approach, but there are a number of inherent risks that
may result in many patients being overtreated.
The first is that the level at which patients are identi-
fied as being not under good control (one or more of
the following over the previous 4 weeks: daytime symp-
toms >2 days/week, need for reliever >2 days/week,
any limitation of activities or any symptoms during the
night or on waking) is set so low that many patients
may receive an unnecessary step up in treatment in an
attempt to achieve good control. Over time, this
approach will result in most patients with asthma
receiving inhaled corticosteroid (ICS)/long-acting beta
agonist (LABA) therapy, regardless of the initial treat-
ment requirements.4
The second is that the ICS doses which achieve at
least 80–90% of the maximum therapeutic benefit have
been called ‘low’ doses,5 and that two additional dose
levels of ‘moderate’ (up to twofold higher) and ‘high’
(over twofold higher) doses are recommended above
this level.1,3 This terminology encourages the prescrip-
tion of higher doses of ICS and ICS/LABA combina-
tions than are necessary, increasing the risk for adverse
effects for little or no additional benefit.6
The third risk is that patients with asthma may have
respiratory symptoms that are not due to asthma.
Although the full guidelines recognize this, a simplistic
approach to stepwise management is likely to result in
an unnecessary increase in asthma treatment in patients
whose symptoms are not primarily due to their asthma,
rather than a focus on the real cause of these symptoms.
This has led to the concept of ‘treatable traits’ in which
the potential role of endotypes, overlapping disorders,
co-morbidities, environmental and lifestyle factors con-
tributing to respiratory symptoms are considered in all
patients, and investigated and treated accordingly.7
These potential risks come into focus with the publi-
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
similar asthma prevalence, universal public health ser-
vices and well-educated general practice and specialist
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
the survey is that 82% of ICS users in Australia were
prescribed ICS/LABA combination therapy compared
with only 44% in New Zealand. Despite the more
© 2017 Asian Pacific Society of Respirology
extensive use of ICS/LABA combination therapy in
Australia, this has not led to better asthma outcomes:
Asthma Control Test scores, the proportion of patients
reporting urgent asthma visits and the proportion who
had hospital or emergency department (ED) visits due
to their asthma were similar in the two countries.
Should we be surprised by these findings? Probably
not. In patients with mild or moderate asthma, who
make up the majority of asthmatic population, the
combination of ICS and LABA does not reduce the risk
of exacerbations over that achieved with a similar dose
of ICS alone.9
So where are we headed? We now recognize that
most adults with asthma have some features consid-
ered characteristic of COPD10 and vice versa,11 which
has led to the proposed, but controversial, asthma–
COPD overlap syndrome (ACOS).12 Also, international
asthma3 and COPD13 guidelines now recommend that
treatment should be escalated to ‘triple therapy’ with
maintenance ICS, LABA and long-acting muscarinic
antagonist (LAMA) therapy if necessary to achieve
symptom control and reduce the risk of exacerbations.
This current scenario has the risk that patients with air-
way disease (including asthma, COPD and ACOS) will
be prescribed ‘triple therapy’ as the default position,
similar to the current prescription of ICS/LABA as the
default treatment for adult asthma in Australia. This
potential ‘one size fits all’ approach to the management
of airway disease may be practical, simple and ‘a safe
bet’ in terms of efficacy, but is surely not in the best
interest of patients or government funding agencies,
and is contrary to the precision medicine approach
which has been pioneered in Australia.14 The medical
profession in New Zealand and Australia (and interna-
tionally) needs to work with regulatory authorities,
guidelines groups, not-for-profit non-government orga-
nizations and the pharmaceutical industry to ensure
that triple therapy does not become the default posi-
tion for patients with airway disease.
Richard Beasley,1 Jo Hardy1 and Robert Hancox2
1
Medical Research Institute of New Zealand, Wellington;
2
Department of Preventive and Social Medicine,
University of Otago, Dunedin, New Zealand
Acknowledgement
The Medical Research Institute of New Zealand is supported by
the Health Research Council of New Zealand, Independent
Research Organisation funding.
Disclosure statement
R.B. has received payment for lectures from and been a member
of the AstraZeneca, GlaxoSmithKline and Novartis advisory
boards, and received research grants from AstraZeneca,
Respirology (2017) 22, 1487–1488
doi: 10.1111/resp.13159
1488
Cephalon, Chiesi, Genentech, GlaxoSmithKline and Novartis. R.-
H. has received payment to his institution for lectures and/or
advisory boards from AstraZeneca, GlaxoSmithKline and Novar-
tis, and non-financial support from Boehringer Ingelheim.
REFERENCES
1 National Asthma Council Australia. Australian Asthma Handbook:
Australia’s National Guidelines for Asthma Management. [Accessed
22 August 2017] Available from URL: http://www.asthmahandbook.
org.au
2 Beasley R, Hancox RJ, Harwood M, Perrin K, Poot B, Pilcher J,
Reid J, Talemaitoga A, Thayabaran D. Asthma and Respiratory
Foundation NZ adult asthma guidelines: a quick reference guide.
N. Z. Med. J. 2016; 129: 83–102.
3 Global Initiative for Asthma. Global Strategy for Asthma Manage-
ment and Prevention, 2017. [Accessed 22 August 2017.] Available
from URL: http://www.ginasthma.org
4 Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ,
Pauwels RA, Pedersen SE. Can guideline-defined asthma control
be achieved? The Gaining Optimal Asthma ControL study. Am.
J. Respir. Crit. Care Med. 2004; 170: 836–44.
5 Holt S, Suder A, Weatherall M, Cheng S, Shirtcliffe P, Beasley R.
Dose-response relation of inhaled fluticasone propionate in adoles-
cents and adults with asthma: meta-analysis. BMJ 2001; 323: 253–6.
6 Beasley R, Thayabaran D, Hancox RJ. Adult asthma quick refer-
ence guides: Trans-Tasman differences in opinion. Respirology
2017; 22: 9–11.
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Editorial
7 Agusti A, Bel E, Thomas M, Vogelmeier C, Brusselle G, Holgate S,
Humbert M, Jones P, Gibson PG, Vestbo J et al. Treatable traits:
toward precision medicine of chronic airway diseases. Eur.
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
of nationally-representative populations in New Zealand and
Australia. Respirology 2017; 22: 1570–78.
9 Ni Chroinin M, Greenstone I, Lasserson TJ, Ducharme FM. Addi-
tion of inhaled long-acting beta2-agonists to inhaled steroids as
first line therapy for persistent asthma in steroid-naive adults and
children. Cochrane Database Syst. Rev. 2009; http://doi.rog/10.
1002/14651858.CD005307.pub2
10 Travers J, Marsh S, Williams M, Weatherall M, Caldwell B,
Shirtcliffe P, Aldington S, Beasley R. External validity of rando-
mised controlled trials in asthma: to whom do the results of the
trials apply? Thorax 2007; 62: 219–23.
11 Travers J, Marsh S, Caldwell B, Williams M, Aldington S,
Weatherall M, Shirtcliffe P, Beasley R. External validity of rando-
mized controlled trials in COPD. Respir. Med. 2007; 101: 1313–20.
12 Postma DS, Rabe KF. The asthma-COPD overlap syndrome.
N. Engl. J. Med. 2015; 373: 1241–9.
13 Global Strategy for the Diagnosis, Management and Prevention of
COPD. Global Initiative for Chronic Obstructive Lung Disease
(GOLD), 2017. [Accessed July 2017.] Available from URL: http://
goldcopd.org
14 McDonald VM, Higgins I, Wood LG, Gibson PG. Multidimensional
assessment and tailored interventions for COPD: respiratory utopia
or common sense? Thorax 2013; 68: 691–4.
Respirology (2017) 22, 1487–1488