Stepping down asthma treatment guidelines

Transcription

1 Stepping down asthma treatment guidelines The potential for inhaled corticosteroids (ICS) to cause dose-related side-effects has led to asthma management guidelines recommending a dose reduction once asthma control is achieved. By adopting a stepwise approach to the use of ICS, a reduction in the dose can be achieved without compromising asthma control in patients with mild 1,2 moderate or severe disease. 3 A suitable reduction in dose in appropriate patients will make little difference to their disease control but will significantly reduce the potential for side-effects. The following patients should be considered for a reduction of ICS dose: Include patients: with a confirmed diagnosis of asthma and who have been free of asthma symptoms for 3 months or more. Exclude patients: with ongoing symptoms, or needing to use Short Acting Beta Agonist (SABA) e.g. salbutamol, terbutaline three times a week or more [N.B. some patients are still incorrectly directed to use SABAs on a regular basis e.g. QDS not PRN] who have had an exacerbation, oral corticosteroid course, or visit to GP or hospital because of worsening asthma, in preceding three months. with serious illness, substance misuse, or pregnancy. who cannot use a peak flow meter. Method: Check with the patient that their asthma is well controlled. Explain that reducing the dose of ICS reduces the potential for side-effects and ask if they agree to try stepping-down their treatment. Record objective measurements of their current lung function e.g. Peak flow or spirometry, and check inhaler technique by asking the patient to demonstrate. Check the patient s adherence to the prescription for both ICS and SABA; look at the prescription history and calculate usage to see how it matches with expected usage. This will enable you make a better judgement of how or whether to reduce the dose. Check the patient s understanding of the need for daily preventative therapy. Reduce the dose of inhaled corticosteroids slowly (See Flow Charts below). The usual protocol is to decrease the ICS dose by 25% to 50% per 3-month visit. Some children with milder asthma and a clear seasonal pattern to their symptoms may tolerate a more rapid dose reduction during their 'good' season. N.B. A change from a middle range fluticasone preparation e.g.seretide 125 or Flutiform 125/5, to a low range fluticasone preparation e.g. Flutiform 50/5, represents a 60% reduction in ICS dose and additional care is required. If the patient is using a combination inhaler, you may need to consider prescribing separate inhalers for this process or switching to a different device with more flexibility e.g. Fostair or Symbicort. Ideally the dose of LABA (long-acting beta-agonist) should remain constant during this process, so only one drug element is reduced at a time, but this is not always possible when stepping down using combination inhalers. If you are changing to a different ICS, use Appendix 1 to work out the equivalent dose of the new ICS. Explain to the patient the potential for worsening symptoms and the increased risk of an exacerbation. Make sure the patient has an up-to-date written personalised asthma action plan. o A typical asthma action plan should include: o When to increase treatment (as defined by symptoms or peak expiratory flow rate). How to change treatment in case of deterioration and when to go back to maintenance medication. o When to seek medical help. o Agree a review date for 3 months time. Produced by the Prescribing and Medicines Management Team in liaison with the rthants Respiratory Forum Approved by NPAG October 2011, Revised April

2 Appendix 1 Steroid Inhaled Corticosteroid products with BDP equivalent.reference Equivalent dose to Beclometasone dipropionate Beclometasone-CFC Beclometasone Clenil Modulite (CFC-free MDI) Asmabec Clickhaler (dry powder) Becodisks Dry Powder (dry powder) Easyhaler beclometasone (dry powder) Pulvinal (dry powder) Qvar CFC-freeMDI/Easi-breathe/Autohaler Fostair -microfine particlebdp/formoterol CFC-free MDI Budesonide Pulmicort (CFC-free MDI/ Turbohaler ) Easyhaler Budesonide (dry powder) Budelin volizer Symbicort Turbohaler- budesonide/formoterol Fluticasone Flixotide Evohaler CFC-free MDI Flixotide Accuhaler (dry powder) Seretide (CFC-free MDI fluticasone/salmeterol Seretide Accuhaler (Dry powder) Flutiform pmdi Mometasone Asmanex Twisthaler Ciclesonide Alvesco MDI longer available mcg mcg Adapted from the British Thoracic Society and Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Updated Available from For prescribing information please refer to the individual product s Summary of Product Characteristics (SPC). You can view and download SPCs and Patient Information Leaflets (PILs) from the electronic Medicine Compendium (emc) available at 1. Haahtela T et al. Effect of reducing or discontinuing inhaled budesonide in patients with mild asthma. NEngJMed 1994: 331: Leuppi J. et al Predictive markers of asthma exacerbation during stepwise dose reduction of inhaled corticosteroids. AmJRespCritCareMed 2001: 163: Stepping down inhaled corticosteroids in asthma: randomised controlled trial. G Hawkins et al. BMJ2003; 326: Lipworth BJ. Modern drug treatment of chronic asthma. BMJ 1999;318: Produced by the Prescribing and Medicines Management Team in liaison with the rthants Respiratory Forum Approved by NPAG October 2011, Revised April

3 Seretide 50 Evohaler Pt has asthma? Ready for Step Down? Seek advice, as Seretide 50 Evohaler only licensed for asthma. Is patient 18 years or over? 1) QVAR 100 microgram BD, or 2) Clenil 200 microgram BD, or 3) Fluticasone 100 microgram BD [STEP 2] 1) Clenil 200 microgram BD or 2) Fluticasone 100 microgram BD (4 years and older) [STEP 2] Is patient 5 years Flutiform 50/5 Seek advice as Seretide 50 Evohaler is not licensed for children under 5 years of age. Change

4 Seretide 125 Evohaler Pt has asthma? Ready for Step Down? Exclude and seek advice, as Seretide 125 Evohaler is only licensed for asthma Is patient 18 years Is patient 18 years or over? Flutiform 50/5 Is patient 5 years Flutiform 125/5 Seretide 50 Evohaler Exclude and seek advice as Seretide 125 Evohaler is not licensed for children under 12 years of age. Seretide product is licensed for children under 5.

5 Seretide 250 Evohaler Asthma Is patient ready for Step Down? COPD Seretide 500 Accuhaler Is patient 18 years or older? Is patient 18 years or older? Flutiform 250/10 Is patient 12 years Flutiform 125/5 2 Puffs BD Seek advice as Seretide 250 and 125 Evohalers are not licensed for children under 12 years. Change