Asthma management: Australia can do better

Medical practitioners in Australia could be doing more to help patients with asthma, particularly in helping reduce preventable asthma, write Professor Peter Gibson, Professor Phil Bardin, Professor Christine Jenkins and Associate Professor John Blakey.

Too many Australians with asthma do not have an adequate understanding of how to manage their condition.

We also purport that not enough asthma treatment is evidence-based, leading to poorer outcomes (here and here).

Just recently, a study by the University of Queensland found four-year-olds with asthma were more likely to develop anxiety between the ages of six and 15 years compared with non-asthmatic children.

The researchers analysed 9369 parental reports from the Longitudinal Study of Australian Children, which has followed the development and wellbeing of 10 000 children since 2004.

It is clear, now more than ever, we need a reset in how we manage and approach asthma.

Background

Asthma affects people of all ages, races and locations and is one of Australia’s most common chronic medical condition.

Superficially, things have never been so rosy in the world of asthma.

It is one of the few chronic conditions that has an array of efficacious treatments, including inhaled corticosteroids, long-acting b-agonists, long-acting antimuscarinics, and the recent addition of highly effective new drug therapies with relatively few adverse effects, including novel biological agents.

Most asthma attacks and deaths appear preventable when using these treatments in accordance with well established national and international guidelines.

Unlike many countries, asthma therapies are both widely available and subsidised by the government in Australia.

Our national researchers also produce world-leading research and policy on both asthma treatment and effective approaches to asthma care.

In addition, national funding and primary health care initiatives have included asthma in the past. Scratch below the surface, however, and serious problems are evident which we outline below.

Disenfranchised and disempowered

People with chronic conditions must manage their illness all year with only occasional input from their GP or specialist.

Unfortunately, many people with asthma do not recognise what optimised asthma care looks like, or how well controlled their asthma can be. 

There is strong evidence that poor asthma control is the norm in Australia, and data presented at the recent Thoracic Society of Australia and New Zealand conference revealed the situation is, if anything, deteriorating.

It is well established that people who experience suboptimal asthma control have lower quality of life and higher rates of low mood and anxiety. They are also more likely to be unwell with adverse environmental events such as bushfires and thunderstorms. Notably these features are most pronounced in those dwelling in rural and remote areas.

There are highly effective remedies for this since guideline-based care can prevent asthma attacks, persistent symptoms, permanent airway damage, and death from asthma.

Written asthma action plans can ameliorate harm, but national data from the Australian Bureau of Statistics shows three in four adults with asthma do not have one.

We need to do better but most patients (and seemingly many health care professionals) are unaware more could be done, and those that do recognise the problem are often uncertain of how to effect change.

Uninformed and misinformed

A cardinal problem we must face collectively is that, for a diverse array of reasons, asthma management in Australia often does not follow evidence-based guidelines and thus appears suboptimal.

This starts from suboptimal diagnosis, where a minority of people receive objective testing for a condition that will affect them for decades.

Practising this way in another chronic disease, such as never measuring blood sugar for presumed diabetes or blood pressure for hypertension, would be inconceivable; yet it is the rule rather than the exception in asthma.

After receiving a presumptive diagnosis of asthma, as noted above, it is common for people not to receive inhaled corticosteroids in accordance with national and international guidelines, and not to be stepped up to further treatments if control is suboptimal. Referral to a specialist clinic if they have persisting instability also appears suboptimal as it is in other countries.

Fewer than 10% of health care professionals in the United Kingdom can accurately demonstrate correct inhaler technique with common pressured devices, and mastery of dry powder devices is also uncommon in Australia. Many do not recognise and address other risk factors for attacks, such as the worryingly low levels of adherence with inhaled therapy which are prevalent in Australia and many similar countries.

The failure to follow guideline-based care is likely to lead to thousands of preventable emergency room visits annually for asthma exacerbations.

Undertreated and overtreated

The failure to implement high quality asthma care at scale means many people are undertreated on a daily basis, and thus take large amounts of rescue medicines: short-acting b-agonists (ie, salbutamol) and prednisolone. 

Prednisolone can be life-saving, but it is also toxic, leading to a wide variety of harms including increased risk of heart disease, blood clots, diabetes, stomach ulcers, osteoporosis and cataracts. Alarmingly, these toxic side effects have been shown to occur after cumulative doses as low as 500 mg.

Of particular concern in Australia is that patients are commonly dispensed a bottle of 30 x 25 mg prednisolone tablets as rescue medication for an asthma attack, significantly in excess of the number of tablets actually required for burst therapy.

The heavy use of salbutamol in Australia is closely linked to its availability as an over-the-counter medication. Salbutamol has no role as a preventer: it does not treat inflammation and can worsen it, thus as-needed regimes containing inhaled steroids are superior whether in a combination or separate devices. Relying on short-acting b-agonists is analogous to repeatedly pumping up a tyre with a hole in it: sooner or later the problem will recur, often with calamitous consequences. Salbutamol also releases propellants that are highly active greenhouse gases contributing to climate change.

The future of asthma in Australia

This disturbing situation and state of asthma care has prompted a coalition of asthma experts from across the country to join forces to work towards solutions for these urgent issues.

We have formed the Future of Asthma collaboration, which brings together colleagues from clinical practice, academia, learned institutions, and charities, and will be working on a series of events and publications over the next year.

Although worrisome, there is tremendous opportunity to improve our failing grades.

The issues mentioned above are specific and can be well defined; most appear tractable with tools in our possession.

Although key challenges remain with respect to embedded behaviours, a collective and concerted approach has the potential to realise significant improvements in outcomes.

Professor Peter Gibson is a respiratory physician at John Hunter Hospital in Newcastle and the Director of the University of Newcastle’s Priority Research Centre for Healthy Lungs.

Philip Bardin leads the Respiratory and Lung Research Group, is a Professor of Respiratory Medicine in the Faculty of Medicine at Monash University and the Director of Monash Respiratory and Sleep Medicine at Monash Medical Centre in Melbourne. 

Dr John Blakey is a Respiratory Physician with a clinical interest in asthma. He is an advisor for Asthma Australia and Asthma WA and is the branch president of the Thoracic Society of Australia and New Zealand (TSANZ).

Professor Christine Jenkins is a respiratory physician and based at the George Institute for Global Health where she leads clinical trials in airways disease. She has academic appointments at UNSW Sydney and University of Sydney and is a Director of the Board of Lung Foundation Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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