Asthma is one of the most common conditions we see in primary care and can result in significant morbidity and mortality if not diagnosed and managed optimally [1]. The National Heart, Lung, and Blood Institute (NHLBI) has sponsored a consensus panel to develop clinical practice guidelines for child and adult asthma since 1989 [2]. The guidelines were updated at the end of 2020 for the first time in over a decade [3]. The published update is over 300 printed pages; however, for primary care clinicians there is a 16-page guide [4] and a 6 page “at a glance” guide which presents the clinical recommendations in a stepwise approach based on age [5].
The 2020 update is focused on the following six topics:
- Intermittent Inhaled Corticosteroids
- Long-acting Muscarinic Antagonists
- Indoor Allergen Mitigation
- Immunotherapy in the Treatment of Allergic Asthma
- Fractional Exhaled Nitric Oxide Testing
- Bronchial Thermoplasty
Below are some points made in the clinician guide:
Intermittent Inhaled Corticosteroids
Daily inhaled corticosteroid (ICS) treatment is currently the preferred pharmacologic controller therapy for persistent asthma in individuals of all ages. Recommendations are presented by age groups: 0-4 years, 5-11 years, 12 years and older. If either short or long-acting beta-adrenergic agonists (SABA, LABA) are needed for symptom control, they should preferably be combined with ICS as single maintenance and reliever therapy (SMART).
Long-Acting Muscarinic Antagonists
Long-acting muscarinic antagonists (LAMA) are useful for patients who have co-morbidities precluding the use of LABA. Adding LAMA to LABA or ICS-LABA gives a small marginal benefit. Combination triple therapy SMART inhalers are not currently approved for asthma in the US, so multiple inhalers are necessary for triple therapy. LAMA may be harmful to people at risk for glaucoma or urinary retention.
Indoor Allergen Mitigation
Studies reviewed for this update provided little evidence that allergen mitigation strategies are beneficial for improving asthma outcomes.
Immunotherapy in the Treatment of Allergic Asthma
If there is a clear relationship between allergen exposure and asthma symptoms, subcutaneous immunotherapy (SCIT) may be helpful, but sublingual immunotherapy (SLIT) has not shown any benefit for asthma in the studies reviewed.
Fractional Exhaled Nitric Oxide Testing
For ages 5 and above, fractional exhaled nitric oxide testing (FeNO) may be useful in diagnosing asthma if history, physical, and spirometry findings are inconclusive. FeNO levels may be increased in respiratory allergy conditions without asthma.
Bronchial Thermoplasty
Most individuals 18 years and older with uncontrolled, moderate to severe, persistent asthma should not undergo bronchial thermoplasty (BT) to treat asthma because the benefits are small, the risks are moderate, and the long-term outcomes are uncertain. BT has not been studied in individuals younger than age 18.
It’s important to note that the NHLBI asthma guidelines are not the only asthma guidelines updated recently; the European Respiratory Society/American Thoracic Society and Global Initiative for Asthma (GINA) which collaborates with both NHLBI and the World Health Organization have both published recent updates [6,7]. Both guidelines have pocket guides for clinicians [8,9]. A recent editorial explains some of the differences between guidelines [10].
Several biologics directed at immune and inflammatory mediators for asthma currently approved by the FDA for adolescents and adults are being marketed heavily both to clinicians and consumers [11]. As primary care clinicians, we are faced with the dilemma of selecting those patients who will benefit from therapies that require significant expense for the evaluation, therapy, and special facilities that can deliver them. Federally endorsed guideline recommendations are generally followed by Centers for Medicare and Medicaid Services (CMS) and commercial insurance for coverage in the United States. As a primary care practitioner, I look forward to further NIH consensus guidance on severe asthma evaluation and management in light of these new options.
References
Internet links for the references cited below were accessed August 6, 2021:
- CDC: National Center for Health Statistics – Asthma. https://www.cdc.gov/nchs/fastats/asthma.htm
- NHLBI: National Asthma Education and Prevention Program (NAEPP). https://www.nhlbi.nih.gov/science/national-asthma-education-and-prevention-program-naepp
- NHLBI: 2020 Focused Updates to the Asthma Management Guidelines. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines
- NHLBI: 2020 Focused Updates to the Asthma Management Guidelines: Clinician’s Guide. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/clinician-guide-2020-focused-updates-asthma-management-guidelines
- NHLBI: 2020 Focused Updates to the Asthma Management Guidelines: At-a-Glance Guide. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/at-glance-2020-focused-updates-asthma-management-guidelines
- Holguin F, Cardet JC, Chung KF, Diver S, Ferreira DS, Fitzpatrick A, Gaga M, Kellermeyer L, Khurana S, Knight S, McDonald VM, Morgan RL, Ortega VE, Rigau D, Subbarao P, Tonia T, Adcock IM, Bleecker ER, Brightling C, Boulet LP, Cabana M, Castro M, Chanez P, Custovic A, Djukanovic R, Frey U, Frankemölle B, Gibson P, Hamerlijnck D, Jarjour N, Konno S, Shen H, Vitary C, Bush A. Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2020 Jan 2;55(1):1900588. https://erj.ersjournals.com/content/55/1/1900588.long
- Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. https://www.ccjm.org/content/87/9/569.long
- ERS Pocket Guidelines. Management of Severe Asthma: a European Respiratory Society/American Thoracic Society Guideline. https://erj.ersjournals.com/content/erj/55/1/1900588/DC1/embed/inline-supplementary-material-2.pdf?download=true
- GINA: Pocket Guide for Asthma Management and Prevention, updated 2020. https://ginasthma.org/wp-content/uploads/2020/04/Main-pocket-guide_2020_04_03-final-wms.pdf
- Krishnan JA, Cloutier MM, Schatz M. National Asthma Education and Prevention Program 2020 Guideline Update: Where Do We Go from Here? Am J Respir Crit Care Med. 2021 Jan 15;203(2):164-167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874432/
- McGregor MC, Krings JG, Nair P, Castro M. Role of Biologics in Asthma. Am J Respir Crit Care Med. 2019 Feb 15;199(4):433-445. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835092/
Charles A. Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA
charless@culmoreclinic.org
Published on 10/22/2021
