Australian Doctor Australian Doctor 27th October 2017

Therapy Update from previous page KEY POINTS storm asthma epidemics, and interestingly, whether or not Asian ethnicity is an independent risk factor. 8 During the November 2016 epidemic, people of South-East Asian or Indian descent were dispropor- tionately affected, but it is unclear whether this was due to genetic, environmen- tal or cultural factors. 8 Another question is the degree of risk for children. During the November 2016 epidemic, the greatest increase in cases and worst outcomes were among adults. 8 Who is at risk of thunderstorm asthma? • People with seasonal allergic rhinitis (with or without asthma). • People with asthma (or a history of asthma). • People with undiagnosed asthma. Grass pollen allergy is the common factor, but people may not know that they are sensitised. What are current recommendations for preventing thunderstorm asthma epidemics? • Ensure good year-round asthma control, including prescription of regular inhaled corticosteroids according to current national recommendations (indicated for most adults and adolescents). Preventive recommendations Recommended prevention measures vary depending on known risk profile. 9 Advise all at-risk patients (anyone with seasonal aller- gic rhinitis or asthma) to avoid exposure to thunder- storms in spring and early summer, especially during wind gusts just before the storm breaks. Advise these patients to stay indoors with windows closed and the air condi- tioner off or on recirculation mode, or shut car windows and recirculate air. Wearing a protective mask is not currently rec- ommended as part of stand- ard prevention. People with current or recent asthma Manage asthma according to current national guidelines. Most adolescents and adults require regular, low-dose inhaled corticosteroids. 10 For those not taking a regular preventer, assess the individual’s current and past pattern of symptoms. For those with only seasonal asthma, or no reported sea- sonal tendency for asthma but seasonal allergic rhinitis, commence low-dose inhaled corticosteroids six weeks prior to pollen/thunderstorm season and continue into early summer (ideally 1 Sep- tember-31 December). Demonstrate correct inhaler technique and regu- larly check technique and adherence. Review for allergic rhini- tis and treat if present (see advice for patients with allergic rhinitis). Advise patients to carry a reliever at all times and replace it before the expiry date or when few doses are left. Provide a written asthma action plan that includes thunderstorm advice. People with any history of asthma Reassess whether regular inhaled corticosteroids are indicated. Consider aller- gies, seasonality of symp- toms, time elapsed since the 28 • Use seasonal preventive inhaled corticosteroids (1 September-31 December) for the minority of adults and adolescents with asthma who do not otherwise require a regular preventer. • Use seasonal preventive intranasal corticosteroids (1 September–31 December) for patients with seasonal allergic rhinitis. last asthma flare-up, sever- ity of previous asthma, and other medical, psychologi- cal and social factors when assessing need for a regular preventer. People commonly deny or downplay mild asthma symptoms. When patients with a previous asthma diagnosis report that they no longer have asthma, care- ful questioning is needed to confirm they have experi- enced absolutely no asthma symptoms (including during exercise). For anyone who has expe- rienced asthma symptoms triggered by a thunder- storm, commence low-dose inhaled corticosteroids six weeks prior to pollen/ thunderstorm season and continue into early summer (ideally 1 September-31 December). Review for allergic rhini- tis and treat if present (see advice for patients with allergic rhinitis). Explain how to recog- nise asthma symptoms and what to do if they emerge. Advise patients to carry a reliever at all times and replace it before the expiry date or when few doses are left. Ensure correct device use. Provide asthma first | Australian Doctor | 27 October 2017 APPROXIMATELY 30% OF THOSE PRESENTING TO ED IN MELBOURNE DURING THE NOVEMBER 2016 EPIDEMIC HAD NO HISTORY OF ASTHMA, BUT ALMOST ALL HAD HAY FEVER. aid information, and an updated written asthma action plan. People with allergic rhinitis, but never asthma People with ryegrass pollen allergy are at risk of thun- derstorm asthma. Approx- imately 30% of those presenting to ED in Mel- bourne during the Novem- ber 2016 epidemic had no history of asthma, but almost all had hay fever. 11 It is reasonable to assume that all people with sea- sonal symptoms are allergic to grass pollens, without performing allergy tests. For those with perennial allergic rhinitis, consider allergy testing, using skin prick tests or allergen-spe- cific IgE/RAST blood tests, to identify ryegrass allergy. Although standard radio- allergosorbent tests are no longer used in most pathol- ogy laboratories, the term ‘RAST’ is still commonly used to refer to specific allergen immunoassays For those with known or presumed ryegrass allergy, commence intranasal cor- ticosteroids beginning six weeks before and continu- ing throughout the pollen season. Manage allergic rhinitis according to current guide- lines, and provide an aller- gic rhinitis plan. Explain how to recog- nise asthma symptoms and what to do, including how to use a reliever (ideally with spacer), and provide asthma first aid informa- tion including when to call an ambulance. Ensure appropriate access to a reliever inhaler during www.australiandoctor.com.au grass pollen season. Advise people with seasonal aller- gic rhinitis to either carry a reliever inhaler, or know where to get one when needed (for example, avail- able over the counter from pharmacies, or in a home/

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