Question 30: Should all patients be on Comb Therapy     (Heather, New Farm)		26-Oct-05 07:43
	Up to or More than 30% of patients should be on CT?
	Re: Should all patients be on Comb Therapy     (Moderator, National Asthma Council)	26-Oct-05 10:01
	Treat patient as an individual rather than as a statistic.

Question 32: symptoms control     (E. M., GLENHAVEN)		26-Oct-05 07:44
	is there any reliever like ventolin comes in accuhaler as it easier for hand arthritis patients
	Re: symptoms control     (Moderator, National Asthma Council)	26-Oct-05 10:02
	Ventolin inhalers have inhalation aids to put over the top of the inhaler. Not many people need to use them. Suggest your patient talks to their pharmacist. There are no other devices that have inhaler aids. It also depends on the person and whether they can use the inhaler. Some people with arthritis have difficulty unwrapping the Turbuhaler. You can get devices that help turn the device. If all else fails, consider a nebulliser. For more information, see the AMH.

Question 34: Oxis versus Serevent in combination therapy     (Christopher, Renmark)		26-Oct-05 07:46
	The rep always says that Oxis is better than Serevent due to its rapid onset of action. Has this a role to play in the clincal situation.
	Re: Oxis versus Serevent in combination therapy     (Moderator, National Asthma Council)	26-Oct-05 10:04
	Eformeterol has a more rapid onset than salmeterol but it is not clear how significant this is in the clinical setting. It is confusing for the general public because people on combination therapy like Seretide ask what they should do in an emergency. Some will use Oxis as a reliever which has side-effects of tachycardia which for some people will be more severe and there are questions about tachyphylaxis. Use of short-acting reliever is recommended for emergency situations. Oxis will not work faster than short-acting relievers.

Question 35: He who pays the piper calls the tune! - or does he?     (chester, charleville)		26-Oct-05 07:47
	Not uncommonly, I get patients who have gone for a holiday to St Elsewhere's, seen another GP, and come back with a combination puffer. There is no way in the most stretched imagination that they meed any PBS guidelines! They don't like it when I take them off. Any ideas? (At least with specialists you can ring them, tell them you're unhappy, and get them to write the scripts! - or write a private one!)
	Re: He who pays the piper calls the tune! - or does he?     (Moderator, National Asthma Council)	31-Oct-05 10:55
	In practical terms, the obligation is on you as the prescriber to be satisfied that the PBS requirements are met whenever you write a prescription. The wording is: “Patients who previously had frequent episodes of asthma while receiving treatment with optimal doses of inhaled corticosteroids and who have been stabilised on concomitant inhaled [LABA] and [ICS]”. If your patient has had asthma with symptoms on ICS and is now stabilised on a combination product, you may be justified in continuing the combination product. The fact that a previous prescriber may not have considered the PBS requirements is not your issue.

Question 37: "personal best"     (russell, maroochy river)		26-Oct-05 07:47
	written action plans and the NAC 6 step asthma plan both hinge around "personal bests" for deciding appropriate actions. in my experience very few pts ever really have personal best established. the treatment initiation flow charts ( NAC and GINA guidelines) shown earlier use a gradual step wise upregulation of medications. what does the panel recommend as an adequate tune up to demonstrate "personal best" esp with prof bardin's graph showing continued improvement in patient parameters up to 12/12 later?
	Re: "personal best"     (Moderator, National Asthma Council)	31-Oct-05 10:55
	The determination of adequate control is a difficult issue. The current NAC and GINA criteria are specific and few patients ever achieve ALL criteria. The GOAL study showed how difficult it was for most people to achieve guidelines control … the study also showed how dramatically quality of life for all patients in the study improved. Professor Bardin showed that inflammation and bronchial hyper-reactivity can continue to improve for months with effective treatment. There are some validated ‘control tests’ becoming available that provide a score to assist management, much like a BP or HbA1c.

Question 38: GP review of stable asthma patients     (Sue, Brisbane)		26-Oct-05 07:47
	What would be appropriate period of time between GP reviews for a patient stabilised on their combination therapy?
	Re: GP review of stable asthma patients     (Moderator, National Asthma Council)	27-Oct-05 06:08
	It depends...individual factors include past history, severity of underlying disease, knowledge and adherence. But suggest three monthly.

Question 44: Combination of leukotrione antagonists, symptom controllers & ICS     (Robert, Pambula)		26-Oct-05 07:57
	What are the panels ideas of the use of leukotrione antagonists and other preventers, despite the PBS restrictions?
	Re: Combination of leukotrione antagonists, symptom controllers & ICS     (Moderator, National Asthma Council)	28-Oct-05 04:35
	Leukotriene receptor antagonists are used as steroid sparing agents [ie given with combination therapy and ICS] as the standard of care in the UK for children with asthma. That use is not PBS subsidised but may have merit as a trial in some cases, particularly perhaps in those with rhinitis.

Question 49: severity vs compliance vs in control / not in control     (russell, maroochy river)		26-Oct-05 08:00
	there are so many confusing classifications of severity - both in adults and esp children. they have changed frequently over the yrs since NAC started in 1988. i personally find it impossible to memorise them all without reference to the NAC handbook. surely "in control" vs "not in control" is the simpler more relevant question and in everyday gp land we need to address all the very valid questions raised re adherence / correct device / correct diagnosis / other issues. ie if "not in good control" we need to assess and crank up medication or device technique etc or do whatever we can to achieve"control". this is our aim regardless of severity classification.
	Re: severity vs compliance vs in control / not in control     (Moderator, National Asthma Council)	26-Oct-05 10:12
	You are quite right. New guidelines are focusing much more on control than severity. Consider combination therapy for anyone on between 500-1000 mcg FP or equivalent and still having significant symptoms. Consider the PBS guidelines.

Question 50: Asthma     (Mustafizur, Tara)		26-Oct-05 08:00
	Combination therapy for asthma, when to start and when to stop?
	Re: Asthma     (Moderator, National Asthma Council)	28-Oct-05 04:40
	Think about starting combination therapy for any a patient who is on ICS but still getting symptoms. Patients on low and moderate doses of ICS will generally do better on combination therapy than increasing the ICS dose. When the patient has been stabilised on the combination therapy dose and well controlled for about 12 weeks, stop, and think about back titrating the dose of combination therapy. Stopping the combination and going back to ICS alone may be appropriate for some patients.

Question 51: Spirometry     (Prashanth, Hay)		26-Oct-05 08:00
	Can you please outline the relevance of spirometric readings to GP asthma management - if possible quantitatively.
	Re: Spirometry     (Moderator, National Asthma Council)	26-Oct-05 10:08
	Spirometry is critical for diagnosis. It will help confirm the diagnosis and help differentiate asthma from other common airways problems. The key numbers are the ratio of FEV1 to FVC and reversibility. Spirometry is preferable to peak flow as it is more reproducilbe.

Question 53: Asthma control     (Yasuhiro, Northbridge)		26-Oct-05 08:01
	How important is the role of peak flow readings in assessing asthma control and severity?
	Re: Asthma control     (Moderator, National Asthma Council)	26-Oct-05 10:09
	Peak flow readings may be useful for an individual to monitor their asthma at home. A one-off isolated reading in the surgery is of little help. A series of regular readigns ((BD or after exercise or at work/at home)is helpful in confirming a diagnosis, especailly for exercise induced asthma or occupational asthma.

Question 54: Combined ICS/LABA in respiratory infections     (Megan, Peregian Beach)		26-Oct-05 08:01
	In community pharmacy, we occasionally see scripts during winter for Seretide or Symbicort as a 'one-off' (single inhaler, no repeats) for non-asthmatic patients with respiratory infections (also prescribed antiobiotics) - could you please comment on the appropriateness of this therapy
	Re: Combined ICS/LABA in respiratory infections     (Moderator, National Asthma Council)	27-Oct-05 02:59
	Make sure that asthma is a definite diagnosis. NAC Guidelines do not recommend use of combination products for conditions other than asthma. Consider PBS criteria as well.

Question 57: Combination therapy in asthma     (john, Kalgoorlie)		26-Oct-05 08:03
	How safe are inhaled corticosteroids in childhood with regard to bone growth
	Re: Combination therapy in asthma     (Moderator, National Asthma Council)	27-Oct-05 06:32
	You must balance the benefits of ICS , ie control of symptoms and improved quality of life -against the risk. CAMP study indicates a small growth difference in 1st year on ICS with catch up later, leading to a possible loss of up to 1 cm of adult height. There may be an increased risk of fracture up to 10% but the data is woolly.

Question 61: Prof Fitzgerald     (Neyamul, West Wyalong)		26-Oct-05 08:09
	is there any role of oral steroid in Peadiatric asthma. Thank you
	Re: Prof Fitzgerald     (Moderator, National Asthma Council)	27-Oct-05 03:10
	Yes, for acute severe attacks.

Question 67: use of combination therapy in acute exacerbations     (Leonora, Orange)		26-Oct-05 08:13
	1. Is using combination therapy in acute asthma exacerbations (eg exacerbation secondary to viral URTIs) recommended? Does it result in quicker resolution and more efficient control of the exacerbation? Does it also decrease the frequency of exacerbations? 2. How about the use of combination therapy in post-viral cough in a patient with a tendency to airways hyperreactivity?
	Re: use of combination therapy in acute exacerbations     (Moderator, National Asthma Council)	27-Oct-05 03:18
	Combination therapy is not currently part of NAC guidelines for the treatment of acute asthma. Guidelines do not recommend use of CT for post-viral cough and there is not good evidence for its effectiveness. However, patients with airway hyperresponsiveness may be 'closet asthmatics' - consider PBS criteria.

Question 69: combination therapy and coad     (robyn, nhulunbuy)		26-Oct-05 08:15
	is there a place for the above in patients with sob secondary to coad who require frequent salbutamol?
	Re: combination therapy and coad     (Moderator, National Asthma Council)	27-Oct-05 03:19
	Yes! and check COPD treatment.

Question 70: High doses of combined ICS/LABA     (Toni, Gorokan)		26-Oct-05 08:15
	Doses of Seretide 500/50 2p bd. What are the areas of concern with this type of dose?
	Re: High doses of combined ICS/LABA     (Moderator, National Asthma Council)	31-Oct-05 01:38
	A large metanalysis in 2001 (Holt et al, BMJ 323:253-6) showed that to maintain effective control, most people needed no more than 250 mcg of fluticasone or equivalent a day for maintenance. Using larger doses of ICS may produce some improvement of control but the likelihood of adverse effects is much greater. This is particularly a concern for children where hypoadrenal crisis is possible and some deaths have been described. Of course, a few patients with asthma that is difficult to control may need larger doses of ICS for maintenance, but specialist referral should be considered where doses in excess of 1000 mcg of fluticasone or equivalent are contemplated. Larger doses have been suggested for exacerbations but oral steroids are preferred.

Question 71: OTC products     (kerry, buderim)		26-Oct-05 08:17
	Are NSAIDS contraindicated in all asthmatics? Is there a definitive link in all cases? What do we advise or reccomend. Also what OTC vitamins and herbs specifically are we talking about to avoid in asthmatics. I understand there is a vague link with echinaceae, however is this an established link? Again what do we advise?
	Re: OTC products     (Moderator, National Asthma Council)	27-Oct-05 03:22
	Many people with asthma can take NSAIDS safely. Some herbal remedies may be harmful for people with asthma. See complementary therapies information paper on NAC website for more detail on herbs and other complementary therapies .

Question 72: back titration     (Bonnie, Surfers Paradise)		26-Oct-05 08:17
	how to back titrate dose when patient on combination therapy? If px on combination 2 puff BD --> do you 1. reduce dosage like 1 puff bd then 1 puff daily 2.change from combination to ICS alone regardless of dose If we can reduce dosage when back titrating patient. What would be the time frame for reduction?
	Re: back titration     (Moderator, National Asthma Council)	28-Oct-05 03:54
	Back titration of a patient on combination therapy can be complex. In general, the Asthma Management Handbook recommends reducing the daily ICS dose by one third. This means the patient may need a separate ICS inhaler for a time, as well as the combined product. Depending on the individual circumstance it may be possible to back titrate to ICS only, but carefully review the reasons why the patient was 'stepped up' to combination therapy in the beginning. The time of back titration needs to be tailored to individual circumstances, but consider after there has been effective control for 12 weeks.

Question 73: Asthma prevention     (Van Lanh, Bankstown)		26-Oct-05 08:17
	Kindly advise about Intal and Tilade in preventive groups . Do they have any roles ! Thank you
	Re: Asthma prevention     (Moderator, National Asthma Council)	26-Oct-05 10:15
	Intal - no. Intal Forte - yes. As a non-steroidal inhaled preventer in younger children as step between regular bronchodilator and ICS with MDI and spacer. Intal forte can be very effective for exercise induced asthma. Tilade may not be well tolerated because of taste.

Question 75: Ref.Paedriatic Asthma ( Prof .Fizgerald )     (Neyamul, West Wyalong)		26-Oct-05 08:18
	is there any role of oral prednisolone in Pead.asthma? Thank you
	Re: Ref.Paedriatic Asthma ( Prof .Fizgerald )     (Moderator, National Asthma Council)	28-Oct-05 03:56
	See answer to Question 61

Question 77: Action Plans     (Paul, Longford)		26-Oct-05 08:20
	Under what circumstances should a pharmacist recommend a patient to return to the GP to obtain an action plan
	Re: Action Plans     (Moderator, National Asthma Council)	31-Oct-05 11:58
	The time to suggest to the patient that they should see their GP is when the person’s asthma is poorly controlled, when they are using excessive amounts of Ventolin, when they are not using ICS but have frequent symptoms or they do not have a written asthma action plan. The pharmacist’s advice is often heeded! Point out to the patient how much better they will feel when their asthma is well controlled.

Question 79: Combination Therapy     (Khai Yuen, Melbourne)		26-Oct-05 08:21
	I find that a short course of combined corticosteroids and a beta agonist very helpful in controlling patients who have had a persistent cough with wheezing for some days or weeks. These patients are not asthmatics but most probably are having a viral episode that refuses to go away. My questions is: why is it not recommended that a short of of combined therapy be used? The corticosteroid helps to control the inflammation in the bronchial tree and the combination usually helps the wheeze and cough.
	Re: Combination Therapy     (Moderator, National Asthma Council)	31-Oct-05 10:57
	There is no good evidence that combination therapy (or an ICS) is effective in self-limited viral cough. Where a patient has cough and wheeze, a bronchodilator is worth a try. A careful history may establish that the patient has infrequent asthma with symptoms associated with a viral RTI, as happens with most children. In such cases, the severity of symptoms at presentation will determine the appropriate treatment. Current guidelines recommend oral steroids for management of an acute attack with a preventer being considered where a person has daily symptoms.

Question 80: Lung function     (Bianca, HORSHAM)		26-Oct-05 08:21
	Is there an optimal lung function for the delivery of each delivery devices viz. accuhaler, turbuhaler, MDI, autohaler and nebuliser
	Re: Lung function     (Moderator, National Asthma Council)	28-Oct-05 04:42
	Answer – don’t quite understand the question, but presumably to do with maximal inspiratory flow and can they use the device. Accuhaler is a breath activated device, that is effective at inspiratory flow rates in the range of 30-120L/minute. It is generally not suitable for children under the age of 7 Turbuhaler –AZ says it is clinically effective from 30L/min (but I know there have been discussions about this) MDIs and autohalers don’t depend on inspiratory flow rates after they are triggered. The issue for MDIs is co-ordination, and drug delivery. Best practice is probably MDI and spacer in all age groups. Children over 7 can usually manage an autohaler. Nebulizers. Again, don’t depend on inspiratory flow rates, and are no longer recommended for delivery of medication in asthma attacks. Spacers are now recommended for use in acute asthma, they are cheaper and as effective.

Question 83: Sodium cromoglycate/Nedocromil sodium effiacy vs ICS     (Peppe, Port Kembla)		26-Oct-05 08:23
	ICS and combination ICS + LABA is prescribed more than both Intal and Tilade. Is there a reason for this? Is there a demonstrated effiacacy for ICS more so than with Intal or Tilade(are there any studies that suggest this?) or is it a question of weighing up adverse reactions?
	Re: Sodium cromoglycate/Nedocromil sodium effiacy vs ICS     (Moderator, National Asthma Council)	28-Oct-05 04:37
	ICS are more effective as preventative agents than intal/tilade. However, there are increased risks of side effects which must be balanced against the severity of asthma. Neither intal nor tilade are marketed by the manufacturers, as opposed to various ICS and combination therapies which may account for some prescribing practices. Intal Forte [not intal] is still useful for milder cases, especially younger children, and children of all ages with predominant symptoms of exercise induced asthma, either as a regular preventer or prior to sport as needed. Tilade is disliked because of its taste and probably offers little advantage over Intal forte, despite the previous marketing about being better for cough.

Question 87: Pulmicort nebule mixing     (Bianca, HORSHAM)		26-Oct-05 08:25
	Can pulmicort nebules be mixed with other asthma medication nebules eg. ventolin and/or atrovent in the same nebuliser bowl. Is there a reference available for this combination?
	Re: Pulmicort nebule mixing     (Moderator, National Asthma Council)	31-Oct-05 11:59
	Pulmicort respules should NOT be mixed with other nebulised medications but administered separately, preferably using a T-tube to lessen corneal problems. (J Respir Care Pract, 2004, 117, 26-28) Use with other medications has not been adequately assessed.

Question 88: Leukotriene receptor antagonists     (Peppe, Port Kembla)		26-Oct-05 08:26
	As these class of drugs are relatively new what has been the experience with their use in general? Have they proved more effective than ICS or combination therapy? As their use is mainly targetted towards children what has it's use in adults turned up?
	Re: Leukotriene receptor antagonists     (Moderator, National Asthma Council)	28-Oct-05 04:44
	Monteleukast is positioned as an alternative to low dose ICS for frequent episodic to mild persistent asthma. It is also useful for children with rhinitis and asthma. ICS is a more potent and probably more efficacious therapy. Having said that, monteleukast works within a few days and could be considered prior to ICS, especially in parents who are very anxious about steroid side effects. Adult physicians have never warmed to monteleukast and I suspect they have never really used it because they are not concerned about growth whereas that is a major issue for children with persistent asthma.

Question 95: persistent cough     (Christopher, Renmark)		26-Oct-05 08:36
	Off the subject BUT related to questions 67, 73 and 79. In patients with post-viral cough with 'reactive' airways; is there any evidence that Tilade is helpful or anything else?
	Re: persistent cough     (Moderator, National Asthma Council)	31-Oct-05 12:01
	Cough in this context remains a troublesome problem. There is no convincing evidence that any medication helps although some anecdotal information exists that various treatments (such as Tilade) may provide benefit. The area needs more research. There is no place for a combination product in someone with cough but no wheeze.

Question 98: syrups     (Christopher, Renmark)		26-Oct-05 08:44
	Why are Brondecon and Ventolin syrup still available in Australia? Is their any evidence that their use in asthma is of any benefit?
	Re: syrups     (Moderator, National Asthma Council)	31-Oct-05 12:02
	There is a small place for the use of Ventolin syrup and for theophyllines like Brondecon in 'special needs patients' who are physically or mentally handicapped, but most people are better managed on inhaled therapy. Both medicines are effective for the treatment of asthma but have significant adverse effects. I still see scripts very occasionally for Ventolin syrup for the pre schoolers, perhaps where the diagnosis is uncertain and parents are reluctant to use an inhaler. The syrup is not as effective and there is an increased incidence of adverse effects. Brondecon is available over the counter and still used for bronchitis, but I generally am reluctant to recommend it because of the potential for interactions and adverse effects.

Question 135: Singulair     (Rani, Sydney)		27-Oct-05 08:29
	Is combination therapy recommended for patients taking Singular on regular basis?
	Re: Singulair     (Moderator, National Asthma Council)	28-Oct-05 04:45
	No, the PBS guidelines state this clearly.

Question 149: puffers and spacers     (Louise, DUBBO)		29-Oct-05 12:06
	After explaining the benefit of spacers to parents of children I still have the occasional few that do not see the necessity of spacers as they think their child is using the puffer correctly. Any ideas you may have to help me educate on the importance of spacers would be grateful.
	Re: puffers and spacers     (Moderator, National Asthma Council)	03-Nov-05 02:50
	You are obviously working well with your young patients with asthma and their families. When talking to the parents, I would emphasise the points of better drug delivery to the lungs, and less oropharyngeal deposition (especially when using ICS), and try to work through the barriers to spacers – size, ‘obviousness’. These barriers are not so much an issue if the child is well controlled as they are then mostly using the spacer at home. You may consider loaning the family a spacer for a week to see if the child’s asthma control is better. Actually watching the child use an MDI without a spacer and pointing out any vapour escape can also help reinforce the value of spacers. Compromises may include spacer use at home and puffers at school, and I would suggest using an autohaler instead of an MDI.

Question 150: Back titration     (Jon, Balgownie)		29-Oct-05 05:40
	I have been hearing more about the options of backtitration with doses of ICS therapy. Is it also suitable for the option of backtitration to a monotherapy product from a combi if the pt has been well contrlled for grreter than 3 months?
	Re: Back titration     (Moderator, National Asthma Council)	31-Oct-05 01:39
	Back titration from a combination product to ICS alone is feasible if the patient has been well controlled for a number of months although, in theory, the dose of ICS may need to increase to maintain control. You should discuss whether this is the best option with your patient. A therapeutic trial is always worthwhile but advise the patient to return within a few weeks for review, or earlier if symptom control deteriorates.