2024 Asthma Management Guidelines: A Comprehensive Review

Asthma is a chronic respiratory disease characterized by variable airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. Proper management of asthma is crucial to ensure optimal patient outcomes and quality of life. Several prominent organizations regularly release updated guidelines to improve asthma management based on the latest scientific evidence and clinical practices. These organizations include the National Asthma Education and Prevention Program (NAEPP), Veteran’s Administration/Department of Defense (VA/DoD), the Global Asthma Network (GAN), Global Initiative for Asthma (GINA), Japanese Society of Allergology (JSA), and the European Respiratory Society/American Thoracic Society (ERS/ATS). This article provides a comprehensive overview of the updated asthma guidelines from these organizations, highlighting key changes and their implications for clinical practice.

1. National Asthma Education and Prevention Program (NAEPP) Guidelines

The NAEPP, under the National Heart, Lung, and Blood Institute (NHLBI), updated its guidelines in 2020 after a 13-year gap. The guidelines provide an evidence-based approach to asthma management, focusing on six key areas:

a. Inhaled Corticosteroids (ICS) and Long-Acting Beta-Agonists (LABA):

The 2020 update emphasizes the use of inhaled corticosteroids (ICS) as the cornerstone of asthma management across all severity levels. The guidelines recommend considering the addition of long-acting beta-agonists (LABA) for patients with moderate to severe persistent asthma not well controlled with ICS alone. For mild persistent asthma, the guidelines introduce as-needed low-dose ICS with short-acting beta-agonist (SABA) as an alternative to daily ICS therapy, providing flexibility in management.

b. FeNO Testing:

The updated guidelines introduce the use of fractional exhaled nitric oxide (FeNO) testing as an adjunct in diagnosing asthma and monitoring treatment response, especially in cases where diagnosis is uncertain or symptoms persist despite treatment. FeNO levels correlate with airway eosinophilia and can guide decisions on ICS therapy.

c. Subcutaneous and Sublingual Immunotherapy (SCIT and SLIT):

NAEPP emphasizes the role of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) for patients with allergic asthma who are inadequately controlled on standard therapies. Immunotherapy may reduce symptom burden and the need for medication.

d. Bronchial Thermoplasty:

For patients with severe, uncontrolled asthma despite maximal therapy, the guidelines mention bronchial thermoplasty as a potential intervention. This technique involves delivering controlled radiofrequency energy to reduce smooth muscle mass in the airways, potentially reducing exacerbations and improving quality of life.

e. Use of Biologics:

The NAEPP guidelines recognize the growing role of biologics (e.g., omalizumab, mepolizumab, benralizumab, dupilumab) in the management of severe asthma. The guidelines provide recommendations on selecting appropriate biologic therapy based on patient phenotype, biomarkers, and clinical response.

f. Asthma Action Plans and Monitoring:

Updated NAEPP guidelines emphasize the importance of personalized asthma action plans, patient education, and regular monitoring to achieve and maintain asthma control. The guidelines recommend the use of validated questionnaires like the Asthma Control Test (ACT) to assess control and guide therapy adjustments.

2. Veteran’s Administration/Department of Defense (VA/DoD) Guidelines

The VA/DoD guidelines provide a unique perspective by integrating asthma management within military and veteran populations, addressing specific challenges such as deployment, occupational exposures, and comorbidities.

a. Stepwise Approach to Management:

Similar to NAEPP, the VA/DoD guidelines advocate for a stepwise approach to asthma management, starting with low-dose ICS and escalating therapy based on control and severity.

b. Consideration for Occupational Asthma:

The guidelines emphasize the need for screening for occupational asthma in military and veteran populations due to potential exposure to dust, chemicals, and other respiratory irritants during service. Removal from exposure and appropriate medical management are essential components of care.

c. Role of Pulmonary Rehabilitation:

VA/DoD guidelines highlight the role of pulmonary rehabilitation for patients with asthma, particularly those with comorbidities like COPD or other functional limitations. Pulmonary rehabilitation can improve exercise capacity, reduce symptoms, and enhance overall quality of life.

3. Global Asthma Network (GAN) Guidelines

The Global Asthma Network (GAN) aims to provide an international framework for asthma care, focusing on epidemiology, public health interventions, and global standardization of care.

a. Focus on Low- and Middle-Income Countries (LMICs):

The GAN guidelines prioritize strategies to improve asthma management in low- and middle-income countries (LMICs) by promoting access to affordable medications, training healthcare professionals, and improving diagnostic capabilities.

b. Environmental and Lifestyle Interventions:

GAN emphasizes the importance of environmental control and lifestyle modifications in managing asthma. The guidelines advocate for reducing indoor and outdoor air pollution, controlling allergens, and promoting smoking cessation.

c. Global Standardization of Care:

GAN guidelines promote the global standardization of asthma care by recommending universal access to essential medicines and diagnostic tools, aligning with World Health Organization (WHO) priorities.

4. Global Initiative for Asthma (GINA) Guidelines

The Global Initiative for Asthma (GINA) guidelines are among the most widely recognized and adopted globally. The 2021 update introduces several key changes in asthma management:

a. Removal of SABA-Only Treatment for Mild Asthma:

One of the most significant changes in the GINA guidelines is the removal of SABA-only treatment (e.g., albuterol) for mild asthma due to the risk of exacerbations and poor outcomes. Instead, GINA recommends low-dose ICS-formoterol as the preferred reliever therapy across all severity levels.

b. ICS-Formoterol as a Single Maintenance and Reliever Therapy (SMART):

The guidelines endorse the use of ICS-formoterol as both maintenance and reliever therapy (SMART) for moderate to severe asthma. This approach simplifies treatment regimens, reduces exacerbations, and minimizes the risk of side effects associated with high-dose ICS.

c. Personalized Asthma Management:

GINA emphasizes the importance of personalized asthma management based on individual patient factors, including phenotype, biomarkers (e.g., blood eosinophils, FeNO), and response to therapy. Tailoring treatment improves outcomes and reduces the burden of asthma.

d. Non-Pharmacological Interventions:

The GINA guidelines also address non-pharmacological interventions such as weight loss, smoking cessation, and avoiding exposure to allergens and pollutants. These measures complement pharmacotherapy and contribute to overall asthma control.

5. Japanese Society of Allergology (JSA) Guidelines

The Japanese Society of Allergology (JSA) guidelines focus on asthma management within the Japanese population, considering genetic, environmental, and healthcare system factors unique to Japan.

a. Emphasis on Biomarker-Guided Therapy:

JSA guidelines advocate for the use of biomarkers such as serum IgE, eosinophil count, and periostin to guide treatment decisions. This personalized approach helps identify patients who may benefit from biologic therapies.

b. Stepwise Pharmacological Management:

The JSA follows a stepwise approach similar to other guidelines but emphasizes low-dose ICS and leukotriene receptor antagonists (LTRAs) for mild asthma. For moderate to severe asthma, the guidelines recommend combination therapy with ICS/LABA and consideration of add-on therapies such as LTRAs or biologics.

c. Patient Education and Self-Management:

Patient education is a cornerstone of the JSA guidelines, with an emphasis on self-management skills, adherence to prescribed therapy, and regular follow-up visits to optimize asthma control.

6. European Respiratory Society/American Thoracic Society (ERS/ATS) Guidelines

The ERS/ATS guidelines provide evidence-based recommendations for severe asthma management, focusing on complex cases that require specialized care.

a. Definition and Classification of Severe Asthma:

ERS/ATS defines severe asthma as asthma that remains uncontrolled despite optimized therapy with high-dose ICS/LABA or requires high-dose ICS to maintain control. The guidelines provide a detailed classification to guide treatment decisions.

b. Phenotype- and Biomarker-Driven Therapy:

The ERS/ATS guidelines advocate for phenotype- and biomarker-driven therapy, similar to other guidelines. Recommendations include using FeNO, blood eosinophils, and serum periostin to guide biologic therapy choices.

c. Comprehensive Multidisciplinary Approach:

For patients with severe asthma, the guidelines recommend a multidisciplinary approach involving pulmonologists, allergists, and other specialists to address comorbidities, optimize medication regimens, and consider advanced therapies such as bronchial thermoplasty or biologics.

7. Common Themes and Differences Across Guidelines

While the updated asthma guidelines from NAEPP, VA/DoD, GAN, GINA, JSA, and ERS/ATS share common themes, such as the emphasis on ICS-based therapy, personalized management, and the role of biologics, there are notable differences:

Use of Reliever Medications: GINA uniquely recommends ICS-formoterol as the preferred reliever therapy for all asthma patients, while other guidelines still include SABA as an option for mild asthma.

Role of Biomarkers: JSA and ERS/ATS guidelines place a stronger emphasis on biomarker-guided therapy, whereas NAEPP focuses more on clinical symptoms and exacerbation history.

Approach to Severe Asthma: ERS/ATS provides the most detailed guidance on managing severe asthma, with specific recommendations for multidisciplinary care and advanced therapies.

Conclusion

The updated asthma guidelines from these leading organizations provide a comprehensive framework for managing asthma, emphasizing personalized care, evidence-based treatment options, and multidisciplinary approaches for severe cases. Clinicians must stay abreast of these updates to optimize asthma care and improve patient outcomes.