New Asthma Guidelines Mark Significant Shift in Asthma Management

The National Institutes of Health’s (NIH) newly released asthma management guidelines include significant changes to the recommendations for the treatment of adolescents with the disease, including the use of single maintenance and reliever therapy (SMART) with inhaled corticosteroid (ICS)-formoterol therapy as the preferred daily controller and as-needed rescue therapy option in steps 3 and 4.

Listen to guideline coauthor Anne Dixon, MD, explain the newest updates to asthma management in a podcast interview with the American Lung Association.

The National Asthma Education and Prevention Program’s guideline updates are the culmination of work that began with a 2014 needs assessment and continued with systematic reviews of the latest scientific literature. Ultimately, a panel of 19 experts developed 17 new recommendations for people aged 12 and older who have asthma. The recommendations are the first update since 2007.

One of the most significant changes was the strong recommendation to support SMART therapy with low-dose ICS-formoterol in step 3 cases and medium-dose ICS formoterol in step 4. That decision was based on 10 studies involving nearly 21,000 subjects.

“Multiple studies demonstrate that SMART is more effective in reducing a composite measure of exacerbations vs 3 different comparators,” wrote corresponding author Michelle M. Cloutier, MD, of UCONN health, and colleagues.

Those 3 comparators were a higher daily dose of an ICS with an as-needed short-acting β2-agonist (SABA), a daily same-dose ICS plus long-acting β2-agonist (LABA) and an as-needed SABA, and a higher daily-dose ICS plus LABA and an as-needed SABA.

The guidelines for the use of LAMAs marks the first time the federal management guidelines have included guidance on LAMAs in adolescents and adults. The therapy is recommended for long-term asthma control in the ambulatory setting, but not to treat acute asthma in an inpatient or emergency department setting. It also is not recommended for individuals with risk of urinary retention or glaucoma.

Another notable change was the addition of fractional exhaled nitric oxide (FeNO) testing as part of the asthma diagnosis and monitoring process in many situations. Specifically, the guidelines include a conditional recommendation of FeNO measurement as an adjunct in patients 5 years and older when a diagnosis of asthma is uncertain using history, clinical findings and course and spirometry (or when spirometry cannot be performed).

Similarly, when physicians have difficulty choosing, monitoring, or adjusting anti-inflammatory therapies in patients with persistent allergic asthma, the authors said FeNO measurement could be part of the ongoing asthma monitoring and assessment process.

However, the guidelines do not recommend using FeNO measurement in isolation to assess asthma control and exacerbations, or to predict future exacerbations.

The guidelines also recommend against the use of bronchial thermoplasty in adults 18 and older with persistent asthma, though they said patients who place a low-value on potential harms like short-term exacerbation and a high value on the potential for improved quality of life in the long-term “might consider” the therapy.

The Asthma and Allergy Foundation of America (AAFA) praised the NIH for updating its guidelines, though CEO and President Kenneth Mendez, MBA, said the update did not include much about biologic therapies.

“We understand there will be more to come on this with future updates as these drugs have exploded onto the market after the recommendations coming out now were already in development,” he said in a statement. “There’s always room to go further as doctors and researchers continue to learn more about how to treat asthma.”

The guideline, “Managing Asthma in Adolescents and Adults: 2020 Asthma Guideline Update From the National Asthma Education and Prevention Program,” was published online in JAMA.