Treating Severe Asthma
People with severe asthma will use many of the same preventer and reliever medicines used by people with mild to moderate asthma. However, people with severe asthma do not respond as well to these commonly prescribed asthma treatments, and often require additional treatments.
Severe asthma is not the same for everyone. So finding the right treatment options may take time and will differ from person to person.
The goal of asthma treatment, like most medical treatment, is to achieve the best possible level of asthma control with the lowest amount of treatment. People with severe asthma tend to have more symptoms or flare-ups even when taking the highest recommended level of preventer treatment. They may need the highest recommended level of preventer treatment continuously to control their asthma. At this point, a referral to a specialist is recommended.
It’s important your healthcare professional checks your inhaler technique and makes sure you are taking your medicine properly to get the full dose into your lungs every day. Sometimes just a simple tweak to your technique can improve how much medicine makes it to your lungs and this can improve your asthma control. You can check your technique for a range of inhalers by watching the videos here.
People with severe asthma will most likely need to take some of the following medications:
Preventers contain an inhaled corticosteroid, an anti-inflammatory medicine, to reduce the inflammation, sensitivity, and excess mucus in the airways. This will reduce your symptoms and flare-ups and reduce the likelihood of reacting to triggers. Your preventer should be taken every day, usually twice per day, as prescribed.
If you have been diagnosed with severe asthma, you will probably already be on the highest recommended dose of your preventer inhaler.
Combination preventers contain two medicines within the one inhaler.
The first medicine is an inhaled corticosteroid to reduce the inflammation, sensitivity, and excess mucus in the airways. This acts to reduce your symptoms and flare-ups and reduce the likelihood of reacting to triggers.
The second medicine is a long-acting bronchodilator that is used to relax tightened airway muscles. As a long-acting medicine, it is also considered a preventer medicine.
Your inhaled combination preventer should be taken every day as prescribed.
If you have been diagnosed with severe asthma, you will probably already be on the highest dose of your combination preventer inhaler.
Everyone with asthma should have a reliever medication. Relievers are fast-acting medications that give quick relief of asthma symptoms. They open the airways quickly by relaxing the airway muscles. Using your reliever more than two days per week is a sign of uncontrolled asthma.
There is some evidence that people who overuse reliever medications may develop a form of tolerance to the medicine. This means your body starts to get used to the medicine and you need higher doses for it to work or it may not work as well in the case of an emergency.
Blue or grey reliever inhalers, such as Asmol, Ventolin, and Bricanyl, contain only a bronchodilator medication to relax the airway muscles. These products are effective usually between four to six hours. They don’t act to prevent symptoms from occurring again.
Symbicort is a product that is licensed for use as a reliever also. Symbicort is a combination product (see below) containing a corticosteroid and a ‘bronchodilator’ which acts to relax the muscles around the airways. The combination product has been demonstrated to provide both symptom relief to reduce airway inflammation.
Maintenance and Reliever Therapy (Mart) Regime
A ‘maintenance and reliever therapy’ or ‘MART’ regime is the prescription of certain low-dose combination preventers such as DuoResp, Fostair or Symbicort as both maintenance (twice daily preventer) and reliever medication (instead of a blue/grey reliever).
These combination products provide both symptom relief and reduce airway inflammation. The long-acting bronchodilator works quickly to relax tightened airway muscles, just like a blue/grey reliever.
If you have severe asthma, sometimes other types of medication are used together with a preventer and a reliever to help control the symptoms of asthma. These add-on medications are used to reduce asthma flare-ups and can sometimes improve lung function. They should be used with a preventer medication. If you experience asthma symptoms or flare-ups, you will still need to use your reliever inhaler.
Add-on medications for severe asthma include:
This medicine may be an option for people over 18 years who have severe asthma despite regular use of high-dose combination preventer medication.
This treatment works to relax the muscles around the outside of the airway and keep them relaxed for up to 24 hours. It is a once-daily, inhaled medicine and should only be used in addition to anti-inflammatory preventer medicine. It does not replace preventer medication. When used as an add-on treatment to preventer medications it can improve lung function and reduce asthma flare-ups.
Spiriva Respimat does not replace your blue or grey reliever. You should carry your blue or grey reliever medicine at all times in case of asthma symptoms.
People with asthma are sometimes prescribed short courses of oral corticosteroid tablets, such as prednisolone, to help get their asthma under control during a flare-up.
This is a powerful anti-inflammatory medicine that helps by quickly reducing the inflammation in your lungs. It is much stronger than the inhaled corticosteroid that is in your preventer inhaler.
For a small number of people with severe asthma who continue to experience asthma symptoms and frequent flare-ups, their doctor or specialist may prescribe steroid tablets for longer periods. This could be months or years. Your doctor or specialist will only prescribe this if it is necessary to prevent you from having regular flare-ups.
You are more likely to have some side effects if you’re on long-term oral corticosteroid tablets, compared to people who only take a short course when their symptoms get worse. If you take steroids in tablet form for three months or more continually, or if you have three to four courses a year, you’ll be at higher risk of side-effects.
The potential side effects of oral steroids include:
- Weight gain
- Reflux and bloating
- Mood swings
- Poor sleep
- Bone fractures (osteoporosis)
- Susceptibility to infection
- Risk of diabetes
The goal is always to make sure you’re on the lowest dose of medicines needed to manage your asthma and reduce your risk of a potentially life-threatening asthma flare-up.
Your doctor will be aware of the possible side effects of steroid tablets and will monitor the doses and medicines you need for your asthma. To reduce the risk of side effects, your doctor will keep you on the lowest possible dose of steroid tablets. In order to do this, your doctor will keep prescribing your preventer inhaler at the maximum dose. However, you should never stop taking your steroid tablets without speaking with your doctor.
Speak to your doctor about your side effects and discuss your options.
Biologics (Monoclonal Antibodies)
More people living with severe asthma will be able to access life-changing, injectable asthma drugs called biologics therapies following an announcement under the Pharmaceutical Benefits Scheme (PBS) to expand eligibility and relax medical red tape around wait times.
For eligible people, they may now be able to trial one of three new, advanced drugs called monoclonal antibody therapies (biologics therapies) under the PBS.
Biologics therapies are considered ground-breaking as they target pathways in the immune system that cause the problematic airway inflammation seen in asthma. They are indicated for use in severe eosinophilic asthma and severe allergic asthma. Professor Peter Gibson, respiratory physician and Asthma Australia Professional Advisory Council Member says, “biologics therapies make a big difference, for example, a 50 per cent reduction in the rate of severe attacks. We expect to see reduced presentations for asthma attacks in severe asthma patients.”
To be eligible for monoclonal antibody therapy under the PBS, a patient must be under the care of the same specialist for at least a six-month period, or less if they have received a diagnosis by a multidisciplinary asthma clinic team.
Monoclonal antibody therapies are typically administered in a hospital setting, but in some situations, the initiation and continued administration of the treatment may be conducted in primary care, provided specific conditions are met.
For people with diagnosed severe asthma, they can ask their GP about accessing biologics therapies. They will need to be referred to a specialist to be considered for biologics.
Access the new Severe Asthma and COVID-19 resource for consumers and health professionals here.