Asthma management: How the guidelines compare

,; ,; ,

doi:doi: 10.12788/jfp.0501

Applied Evidence

Asthma management: How the guidelines compare

J Fam Pract. 2022 November;71(9):392-397 | doi: 10.12788/jfp.0501

PDF Download

References

1. CDC. Most recent national asthma data. Accessed October 24, 2022. www.cdc.gov/asthma/most_recent_national_asthma_data.htm

2. Akinbami LJ, Santo L, Williams S, et al. Characteristics of asthma visits to physician offices in the United States: 2012–2015 National Ambulatory Medical Care Survey. Natl Health Stat Report. 2019;128:1-20.

3. NHLBI. National Asthma Education and Prevention Program expert panel report 3: guidelines for the diagnosis and management of asthma. NIH Publication 07-4051. 2007. Accessed October 24, 2022. www.nhlbi.nih.gov/sites/default/files/media/docs/EPR-3_Asthma_Full_Report_2007.pdf

4. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2022. Accessed October 24, 2022. https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf

5. NHLBI. 2020 Focused updates to the asthma management guidelines. Accessed October 24, 2022. www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines

6. Lazarus SC, Krishnan JA, King TS, et al. Mometasone or tiotropium in mild asthma with a low sputum eosinophil level. N Engl J Med. 2019;380:2009-2019. doi: 10.1056/NEJMoa1814917

7. Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343:332-336. doi: 10.1056/NEJM200008033430504

8. Suissa S, Ernst P, Kezouh A. Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Thorax. 2002;57:880-884. doi: 10.1136/thorax.57.10.880

9. Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial. Lancet. 2008;372:1065-1072. doi: 10.1016/S0140-6736(08)61448-8

10. Calhoun WJ, Ameredes BT, King TS, et al. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. JAMA. 2012;308:987-997. doi: 10.1001/2012.jama.10893

11. Garg Y, Kakria N, Katoch CDS, et al. Exhaled nitric oxide as a guiding tool for bronchial asthma: a randomised controlled trial. Med J Armed Forces India. 2020;76:17-22. doi: 10.1016/j.mjafi.2018.02.001

12. Honkoop PJ, Loijmans RJ, Termeer EH, et al. Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: a cluster-randomized trial in primary care. J Allergy Clin Immunol. 2015;135:682-8.e11. doi: 10.1016/j.jaci.2014.07.016

13. Peirsman EJ, Carvelli TJ, Hage PY, et al. Exhaled nitric oxide in childhood allergic asthma management: a randomised controlled trial. Pediatr Pulmonol. 2014;49:624-631. doi: 10.1002/ppul.22873

14. Powell H, Murphy VE, Taylor DR, et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomised controlled trial. Lancet. 2011;378:983-990. doi: 10.1016/S0140-6736(11)60971-9

15. Shaw DE, Berry MA, Thomas M, et al. The use of exhaled nitric oxide to guide asthma management: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176:231-237. doi: 10.1164/rccm.200610-1427OC

16. Stam J, Souren M, Zweers P. The onset of action of formoterol, a new beta 2 adrenoceptor agonist. Int J Clin Pharmacol Ther Toxicol. 1993;31:23-26.

17. Evgenov OV, Liang Y, Jiang Y, et al. Pulmonary pharmacology and inhaled anesthetics. In: Gropper MA, Miller RD, Evgenov O, et al, eds. Miller’s Anesthesia. 8th ed. Elsevier; 2020:540-571.

18. Rodrigo GJ, Neffen H. Efficacy and safety of tiotropium in school-age children with moderate-to-severe symptomatic asthma: a systematic review. Pediatr Allergy Immunol. 2017;28:573-578. doi: 10.1111/pai.12759

19. Global Initiative for Asthma (GINA). Asthma, COPD, and asthma-COPD overlap syndrome (ACOS). 2015. Accessed October 24, 2022. https://goldcopd.org/wp-content/uploads/2016/04/GOLD_ACOS_2015.pdf

Dosing of an ICS is based on step therapy regardless of the guideline used and is given at a total daily amount—low, medium, and high—for each age group. When initiating an ICS, consider differences between available treatment options (eg, cost, administration technique, likely patient adherence, patient preferences) and employ shared decision-making strategies. Dosing may need to be limited depending on the commercially available product, especially when used in combination with a LABA. However, as GINA emphasizes, a low-dose ICS provides the most clinical benefit. A high-dose ICS is needed by very few patients and is associated with greater risk for local and systemic adverse effects, such as adrenal suppression. With these considerations, both guidelines recommend using the lowest effective ICS dose and stepping up and down according to the patient’s comfort level.

Give an ICS time to work. Although an ICS can begin to reduce inflammation within days of initiation, the full benefit may be evident only after 2 to 3 months.⁴ Once the patient’s asthma is well controlled for 3 months, stepping down the dose can be considered and approached carefully. Complete cessation of ICSs is associated with significantly higher risk for exacerbations. Therefore, a general recommendation is to step down an ICS by 50% or reduce ICS-LABA from twice-daily administration to once daily. Risk for exacerbation after step-down therapy is heightened if the patient has a history of exacerbation or an emergency department visit in the past 12 months, a low baseline FEV₁, or a loss of control during a dose reduction (ie, airway hyperresponsiveness and sputum eosinophilia).

Weigh the utility of FeNO measurement. The 2020 Focused Updates also recommend considering FeNO measurement to guide treatment choice and monitoring, although this is based on overall low certainty of evidence.⁵ GINA affirms the mixed evidence for FeNO, stating that while a few studies have shown significantly reduced exacerbations among children, adolescents, and pregnant women with FeNO-guided treatment, other studies have shown no significant difference in exacerbations.^4,9-15 At this time, the role for FeNO in asthma management remains inconclusive, and access to it is limited across primary care settings.

Inhaled corticosteroids can begin to reduce inflammation within days, but the full benefit may be evident only after 2 to 3 months.

When assessing response to ICS therapy (and before stepping up therapy), consider patient adherence, inhaler technique, whether allergen exposure is persistent, and possible comorbidities. Inhaler technique can be especially challenging, as each inhaler varies in appearance and operation. Employ patient education strategies (eg, videos, demonstration, teach-back methods). If stepping up therapy is indicated, adding a LABA is recommended over increasing the ICS dose. Since asthma is variable, stepping up therapy can be tried and reassessed in 2 to 3 months.

SMART is preferred

Single maintenance and reliever therapy (SMART) with ICS-formoterol, used as needed, is the preferred therapy for steps 3 and 4 in both GINA recommendations and the 2020 Focused Updates (TABLE^3-5). GINA also prefers SMART for step 5. The recommended SMART combination that has been studied contains budesonide (or beclomethasone, not available in combination in the United States) for the ICS and formoterol for the LABA in a single inhaler that is used both daily for control and as needed for rescue therapy.

Continue to: Other ICS-formoterol...