The 2020 updated guidelines on the management of asthma in adolescents and adults, drawn up by the National Asthma Education and Prevention Program, have been recently published in the magazine JAMA.
The paper begins with the premise that asthma is a major public health problem around the world and is associated with morbidity, mortality and excessive economic costs associated with lost productivity.
Six central topics being covered: intermittent inhaled corticosteroids; additional long-acting muscarinic antagonists; fractional exhaled nitric oxide; mitigation of indoor allergens; immunotherapy; bronchial thermoplasty. Here are some of the recommendations included in the document.
Updates to the step-by-step approach to asthma management
Previous recommendations from the National Asthma Education and Prevention Program Expert Panel recommended stepwise drug therapy to achieve and maintain asthma control at the lowest effective regimen. With this method, therapy is advanced one step until asthma control is achieved and reduced one step after asthma control has been maintained for a sufficient length of time. A six-step design is presented in this new document, maintaining the same definitions of asthma severity.
Two significant changes were introduced in step 3 for moderate persistent asthma. The first concerns the use of single maintenance and reliever therapy (SMART), with low-dose of intermittent corticosteroid-formoterol therapy as a preferred daily controller and rescue therapy as needed.
The second change is the addition of a low-dose intermittent daily corticosteroid plus a long-acting muscarinic antagonist (LAMA) with a short-acting β2-agonist (SABA), for rescue therapy, as a further alternative treatment option for step 3. If a long-acting β2-agonist (LABA) is not used, it is recommended to add a LAMA to the control therapy with intermittent corticosteroids, as opposed to continuing the same dose of corticosteroids in monotherapy.
Corticosteroids prescribed for intermittent use
Summarized in effective summary tables, the recommendations begin by addressing the appropriate prescription of intermittent corticosteroids.
In individuals 12 years of age and older with persistent mild asthma, the Panel recommends a low-dose daily corticosteroid and a short-acting β2-agonist (SABA) as needed for reliever therapy, or an as-needed corticosteroid and a concomitantly used SABA.
For patients in the same age group but with moderate to severe persistent disease, treatment with corticosteroid-formoterol in a single inhaler, used as both a daily controller and reliever therapy, is recommended compared to corticosteroid-β2-agonist therapy, long-acting (LABA) at higher doses as daily control therapy and SABA for rapid relief therapy.
Long-acting muscarinic antagonists
Regarding the use of long-acting muscarinic antagonists (LAMA) as adjunctive therapy, the Panel recommends that in individuals 12 years of age and older with uncontrolled persistent asthma not to add a LAMA to a corticosteroid, compared to adding a LABA to a corticosteroid.In the same individuals, it is recommended to add a LAMA to the LABA-corticosteroid therapy compared to continuing the same dose of LABA-corticosteroid therapy.
Fractionated exhaled nitric oxide in the diagnosis of asthma
According to experts, there is no single definitive test for diagnosing asthma, but it requires the integration of information on symptoms and clinical course, as well as tests. The latter should include spirometry with administration of bronchodilators.
Measurement of fractionated exhaled nitric oxide (FeNO) is recommended as an additional test in the diagnosis of asthma when it is uncertain.
Conversely, this test is strongly discouraged in individuals 5 years of age and older with asthma to assess asthma control, predict future exacerbations, or assess the severity of exacerbations. If used, it should be part of an ongoing monitoring and management strategy.
Allergen reduction strategies in asthma management
In the previous National Asthma Education and Prevention Program Expert Panel Report 3 it was already recommended that all individuals with asthma, of any severity, were evaluated for allergen exposure at home and at work, for symptoms upon exposure, and for sensitization by allergy skin tests or allergen specific IgE. In this new paper, only the effectiveness of indoor allergen strategies in mitigating critical outcomes was examined. Exposure to tobacco smoke, external allergens or pollutants was not included.
Among the recommendations expressed in this area, allergen mitigation interventions as part of routine asthma management are not recommended in individuals with asthma who are not sensitized to specific internal allergens or who do not have symptoms related to exposure to specific internal allergens.
In contrast, in individuals with asthma who have sensitization or symptoms related to dust exposure, the Panel recommends waterproof pillow and mattress covers only as part of a multi-component allergen mitigation intervention, not as a one-component intervention.
Allergen immunotherapy consists of the administration of an aeroallergen by subcutaneous or sublingual injection. The group of experts presented two recommendations in this area.
In individuals aged five years and older with mild to moderate allergic asthma, the use of subcutaneous immunotherapy as an adjunct treatment to standard pharmacotherapy is recommended in individuals whose asthma is controlled at the initiation, buildup, and maintenance phases of immunotherapy.
In individuals with persistent allergic asthma, the Panel advises against the use of sublingual immunotherapy instead.
Bronchial thermoplasty is a procedure that uses radiofrequency energy to reduce the smooth muscle mass of the airways. The treatment is administered in three sessions, using a device that releases energy during a bronchoscopy.
Based on the information reviewed, the Panel advises against the use of bronchial thermoplasty in adults with persistent asthma in individuals aged 18 years and older. On the other hand, bnronchial thermoplasty could be considered in individuals with persistent asthma who place a low value on harms (short-term worsening symptoms and unknown long-term adverse effects) and a high value on potential benefits (improvement in quality of life, a small reduction in exacerbations).
Significant changes in patient management
Bronchial asthma is a quite common condition in the population and the guidelines on this topic have a strong impact on daily clinical practice.
These new recommendations will lead to significant changes in the management of patients with moderate persistent disease, in particular regarding the use of single maintenance and reliever therapy, the SMART therapy.
Also, the update for the first time, includes guidance on how to use LAMA in adolescents and adults, the usefulness of the fractionated exhaled nitric oxide test in the diagnosis and monitoring of asthma, and the use of bronchial thermoplasty. The update also provides interesting considerations on the use of immunotherapy and allergen mitigation strategies.
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