Event Recording: A Major Update to Asthma Prescribing in Wales

On Monday 18th March 2024, we held an interactive live virtual event for all primary and secondary care healthcare professionals who are involved in the management of patients living with Asthma, following updates to the All Wales Adult Asthma Management and Prescribing Guideline.

The event was hosted by Dr Katie Pink (Consultant Respiratory Physician and National Asthma Clinical Lead), and featured experts Debbie Hartman (Specialist Respiratory Nurse) and Jackie Reynolds (Respiratory Pharmacist Prescriber).

Updated Guideline

Updated Supporting Notes

Thank you to everyone who submitted questions for the Q&A session at the end of the event. The panel answered as many as they could in the time, but there were a few unanswered questions which they have since provided a written response to:

Previous study has advised an acute saba and aerochamber if on MART , may never be required. But due to inspiration rate Dpi unsuitable?

Even during acute asthma exacerbations most people will have the inspiratory strength to be able to use a dry powder inhaler. Indeed by using MART when they start to become more breathless it should help to prevent such a severe situation developing that they lose inspiratory strength. Very rarely individuals with severe fixed airflow obstruction due to asthma may experience this situation and this would be a rare exception when a SABA MDi could be provided as part of an emergency pack.

The new guideline mentions MART can be used once per day (seven times a week) before need to think about stepping up - how long would you think daily use of once a day reliever dose could continue for before we would be concerned

For those patients using anti-inflammatory reliever therapy (or MART) each extra dose taken provides additional controller medication and hence helps to prevent exacerbations. The cut off of >2 doses of reliever therapy a week indicating poor control does not therefore apply for the preferred regimen. The average frequency of reliever doses of ICS/formoterol over a 4 week period should be considered. If persistent rescue doses beyond the maintenance dose are required (as a guide >7 per week), this should be considered when reviewing the necessary maintenance dose and need for add on therapy.

We have just had a patient that has cataracts from his steroid inhaler - informed by an optician. He no longer wants to use symbicort 200 MART, but has poor control. What would you advise?

There is a far greater risk of developing cataracts with oral steroids than with inhaled steroids and so I would discuss this with the patient (and if inhaled steroids are not used regularly the patient is likely to end up on oral steroids). I would also emphasise the risks of poor asthma outcomes and asthma related death if asthma is undertreated.

What about exercise induced asthma 2-3 times a week only when on a run/cycle?

Exercise induced asthma is a manifestation of poorly controlled asthma. The All Wales (and GINA) guidelines support the use of anti-inflammatory reliever medication for this condition.

What do you class as lower dose for symbicort - 200 or 100?

Symbicort 200/6 has been the dose studied for use as an anti-inflammatory reliever agent. Symbicort 100/6 is very low dose (see table of equivalence in supporting notes)

Where does theophylline sit in the treatment of asthma?

Theophylline is an older drug. It has a narrow therapeutic window with a high side effect profile and hence is rarely used any more. It can work as a bronchodilator in some patients with difficult to control asthma. The guidelines state ‘Oral theophylline is a further add-on therapy that can be trialled at step 5 (usually done on recommendation of secondary care)’.