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Australian Journal of Pharmacy : September 2006
pharmacy pro pharmacy professional updates Review examines asthma self-management options A Nextensive literature review under- taken by the Woolcock Institute of Medical Research has examined the pharmacological strategies for self-man- agement of asthma exacerbations in adults, including those using inhaled cor- ticosteroid/long-acting ß2-agonist (ICS/ LABA) therapy. The review provides evidence-based recommendations on the best way to use oral corticosteroids (OCS) to treat severe exacerbations, and asks whether studies support the common practice of doubling inhaled corticosteroids (ICS) doses as a form of treatment. It examines whether increasing ICS to high doses is an alterna- tive to OCS, as well as the effects of increasing the dose of combination ther- apy during exacerbations. Use of ICS/LABA for maintenance and relief, and the effectiveness of short-acting ß2-agonist (SABAs) in the management of exacerbations have also been addressed. Dr Helen Reddel of the Woolcock Institute and Dr David Barnes from Royal Prince Alfred Hospital, authors of the narrative review (published in the European Respiratory Journal), said the pro- ject was undertaken to help clinicians determine what specific therapeutic instructions should be included in written asthma action plans. Dr Reddel said most of the advice in current international guidelines about managing exacerbations was published prior to the introduction of combination therapy. ‘However recent years have seen an increase in the proportion of patients being prescribed combination inhaled corticosteroid/long-acting ß2-agonist therapy in one inhaler device for the man- agement of persistent asthma,’ she said. ‘The review recognises the importance of written action plans as a beneficial part of an integrated program to substantially improve health outcomes for people with asthma. Our aim was to determine what recommendations should be included in these plans and to make sure they encom- pass patients taking combination therapy.’ The review examined relevant papers published between 1990 and 2004. Key findings include: • Oral corticosteroids are well estab- lished in clinical practice and clinical trials for the treatment of severe exac- erbations, including during treatment with combination therapy. Evidence supports seven-to-10-days treatment with no need to taper except to reduce side effects. • Three studies have shown that dou- bling the dose of ICS is not effective for treatment of exacerbations. • Several studies have shown benefit from high dose ICS (2,400–4,000mg beclomethasone equivalent) for one-to- two weeks. This may be achieved by adding a high-dose ICS inhaler to maintenance ICS or ICS/LABA therapy. • There is inconclusive evidence about acutely increasing the dose of mainte- nance budesonide/formoterol after onset of an exacerbation, and no stud- ies of this approach with fluticasone/sal- meterol. • For patients taking maintenance budes- onide/formoterol, use of the same medication as-needed, including when asthma is worsening, reduces exacerba- tions. Short-acting ß2-agonists are still effec- tive in producing bronchodilation dur- ing combination therapy; however a higher dose may be required. Patients who are taking combination therapy should be reminded that they may use short-acting ß2-agonists for relief of symptoms. ¦ PSA warns against restrictions on compounding A NY moves to extensively curtail the compounding activities of all phar- macists based on the activities of a minority could potentially do much greater harm than good, according to PSA national president Brian Grogan. ‘There were reports [recently in The Age] of a “small nexus” of compounding pharmacists, doctors and marketers sell- ing potentially dangerous “hand-made” drugs that are sold as natural remedies,’ Mr Grogan said. These reports sparked renewed calls for much tighter restrictions on pharmacist compounding. ‘It seems from the reports that the treat- ments produced by this “small nexus” are not evidence-based—and are even harm- ful for patients—and if the reports are true these activities are contrary to PSA’s Code of Professional Conduct. [See www.psa.org.au/ecms.cfm?id=45] ‘PSA’s Code of Professional Conduct states: “A pharmacist must not purchase, 18 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 SEPTEMBER 2006 sell or supply any medicinal product where there is reason to doubt its safety, quality or efficacy or where there is clear, new evi- dence that demonstrates or places doubt on previously established product safety or where a product may impose a hazard to the patient’s health or condition”. ‘PSA would caution, however, that any hasty restrictions could lead to unintended consequences for thousands of patients who receive beneficial evidence-based treatments prepared by pharmacists.’ ¦