P.P. is a 19-year-old adolescent (body weight 65kg) with a medical history of persistent asthma. His current drug profile includes: 

• Fluticasone/Salmeterol 500/50 mcg 1 puff BD; 
• Salbutamol 1-2 puffs Q4-6H PRN for shortness of breath. 

P.P. has had two asthma exacerbations in the past year. PP's most recent pulmonary function testing is as follows: 

• Forced expiratory volume in 1 second ("FEV1") 54% of predicted, 
• Forced vital capacity ("FVC") 78% of predicted; FEV1/FVC 0.64 (ref. > 0.7)
• Peak expiratory flow (personal best) 450 L/minute (ref. 400-700 L/minute) 

Over the past 4 weeks, P.P. states that he has been using the salbutamol inhaler twice weekly and waking once per week because of asthma symptoms. However, P.P. has not been hospitalised due to the worsening in symptoms. 

a) Assess the severity level of P.P.'s asthma according to the Global Initiative for Asthma ("GINA") guidelines. Suggest ONE pharmacist intervention on P.P.'s drug regimen. (2 marks) 

The severity levels in GINA are:

• Difficult to treat
• Severe
• Mild

The patient's asthma is severe according to the GINA guidelines:

• 'Asthma is severe if it is still uncontrolled despite good adherence with high dose ICS-LABA and management of contributory factors, or if the patient needs high-dose ICS-LABA to maintain good asthma control'
  

Patient is on Fluticasone/Salmeterol 500/50 mcg which is high dose ICS-LABA. Contributory factors includes any triggers such as allergens (not mentioned in the question).

Pharmacists intervention (only one requested)

• Check inhaler technique and medication adherence
• Lifestyle advice eg. avoiding allergens and triggers
• Recommending treatment adjustment or escalation, and then prompt referral of patient to clinic if necessary
  • The patient is on Track 2 Step 4 of the GINA treatment algorithm. See if patient can switch to Track 1 using ICS-formoterol instead, which is preferred as it is associated with less exacerbations.
  • Other Add On controller options are long acting muscarinic antagonist (LAMA), or add leukotriene receptor antagonist (LRTA), or house dust mite sublingual therapy (HDM SLT) if applicable

Please go through the GINA guidelines 2024 and GINA severe asthma guide 2024 (check if there are any updated guidelines, tends to update almost yearly)

Refs used in this question:

GINA guidelines:

pg. 13 - How to assess asthma severity

pg. 24 - Treatment Algorithm

pg. 40 - Follow up after exacerbation

pg. 47 - ICS doses and strength

pg. 48 - Recommended inhalers and doses

Severe asthma guide:

pg. 8 - definitions of uncontrolled, difficult to treat, and severe asthma

pg. 10 - decision tree

Essential Role of Pharmacists in Asthma Care and Management J Pharm Pract. 2020