To the Editor: Any doubts that many Australian doctors are prescribing inhaled fluticasone for asthma at inappropriately high doses are dispelled by the three reports in the 3 March issue of the Journal.1-3 Fluticasone has a flat dose–response curve for efficacy and a steep dose–response curve for adverse effects;1 individuals with asthma are receiving high doses of inhaled fluticasone;2 and there is a potential for the effects to be lethal.3

Each of these reports restricted its advice to negative recommendations about drug treatment (DON’T overtreat, BACK-titrate), but this is the right time to also promote positive recommendations about asthma management. All individuals with persistent asthma requiring daily therapy should have either skin testing or in-vitro testing to determine the presence of specific IgE antibodies to inhalant allergens.4 This might allow the option of allergen avoidance. In some studies, dust mite reduction was found to ameliorate asthma symptoms in sensitised individuals (National Health and Medical Research Council Level II evidence), although those findings are not supported by a meta-analysis. Repeated low-dose exposure to cat allergen in cat-allergic individuals with asthma leads to increased non-specific bronchial hyperreactivity (Level II evidence).5 Allergen desensitisation in carefully selected cases with consultant supervision can lead to a significant reduction in medication requirement, and reduced specific bronchial hyperreactivity (Level I evidence).6 Treatment of concomitant rhinitis can itself lead to easier asthma control. A checklist of the “A,B,C...” of asthma triggers does not take long and often yields useful tertiary prevention strategies: Allergy (seasonality, dust, pets), Bronchial infection, Cold air/exercise, Drugs, Emotion/stress, Food and food additives, Gastro-oesophageal reflux, Hormones and pregnancy, Irritants including cigarette smoke, and the Job.

Inhaled anti-inflammatory treatment using cromolyns or corticosteroids, with or without consideration of oral montelukast, remains the cornerstone of asthma control when the disease is frequent or persistent. However, the search for allergic and other triggers by healthcare workers, individuals with asthma, and their carers can instil into the entire group a culture of prevention, which naturally leads to a brake on overtreatment. Such a culture is firmly entrenched in continental Europe and the United States. In Australia, there has been outstanding research into the epidemiology and immunology of asthma, but it’s at the coalface where the individual with asthma gets advice. A diligent search for triggers, with appropriate management, should start at the first consultation, as the pen (or mouse) is poised to prescribe.