New Asthma Guidelines Advise Single Maintenance And Reliever Therapy

In its first asthma guideline update in more than a decade, the U.S. National Heart, Lung, and Blood Institute (NHLBI) recommends "SMART" therapy - a single inhaler containing both an inhaled corticosteroid (ICS) and the long-acting bronchodilator formoterol - for moderate-to-severe persistent asthma, among other guidance aimed mainly at primary care physicians.

"This ICS-formoterol combination therapy is recommended for both daily and when needed therapy in people with moderate-to-severe persistent asthma," Dr. Michelle Cloutier of UCONN Health in Farmington told Reuters Health by email. "This treatment approach not only improves asthma outcomes, including reducing asthma exacerbations, but it also achieves these positive outcomes at a reduced total exposure to corticosteroids."

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"One area of controversy that the 2020 Updates appears to have resolved is the often-used practice of increasing the dose of an ICS during an asthma exacerbation in individuals who are being treated only with an ICS and are adherent to that therapy," said Dr. Cloutier, who chairs the National Asthma Education and Prevention Program (NAEPP) Expert Panel Working Group. "There is good evidence now that this approach is not effective."

The guideline update, published in JAMA, includes 19 recommendations in six key areas of asthma diagnosis, management and treatment developed by the 19-member working group. The recommendations are based on systematic reviews conducted by the Agency for Healthcare Research and Quality and input from NAEPP participant organizations, medical experts, and the public, according to NHLBI.

Key updates include use of:

- Inhaled corticosteroids when needed for recurrent wheezing or persistent asthma;

- Long-acting antimuscarinic antagonists with ICSs for long-term asthma management;

- Allergy shots containing very small amounts of allergen to treat some people with allergic asthma;

- One or more methods to reduce exposure to indoor asthma triggers;

- A fractional exhaled nitric oxide test to help manage asthma or help confirm a diagnosis when the diagnosis is unclear; and

- Bronchial thermoplasty to treat selected adults with persistent asthma.

Dr. Cloutier highlighted features "intended to help primary care providers, specialists, and patients work together to make decisions about the management of their asthma," including:

- An implementation guidance section, which provides expanded summaries to quickly assist clinicians in better understanding the recommendation;

- Clear specifications of the population to which each recommendation applies, as well as exceptions and practical aspects on how to use the recommendation in patient care;

- Information to share with patients so they are well informed to participate in shared decision-making about their treatment; and

- Updated treatment diagrams that incorporate the new recommendations into the stepwise asthma management approach by age group.

JAMA Associate Editor Dr. George O'Connor of Boston University School of Medicine, coauthor of an accompanying editorial, explained the rationale behind the SMART therapy recommendation, which he called "the most important change recommended by the new guideline."

"The prior asthma guidelines recommended, for all patients except those with the mildest asthma, the regular use of an ICS once or twice daily as a controller medication, with a rapidly acting 'quick-relief' inhaler to be used as needed to relieve symptoms," he told Reuters Health by email. "Many patients would forget to take - or decide not to take - the daily ICS, which does not lead to quick relief of symptoms, instead taking only the 'quick-relief' inhaler as needed. Unfortunately, this leads to loss of asthma control and increased risk of severe asthma attacks."

"By linking ICS use to the as-needed use of a 'quick-relief' inhaler, the new guideline promotes a strategy that has been shown in clinical trials to reduce the risk of asthma exacerbations," he concluded.

—Marilynn Larkin

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