Asthma guideline update changes recommendations on mild asthma treatment

The National Asthma Education and Prevention Program focused on six topics in an update to its 2007 asthma guidelines: intermittent inhaled corticosteroids, add-on long-acting muscarinic antagonists, fractional exhaled nitric oxide, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty.

A new guideline update offered updated recommendations on asthma management, including either daily low-dose intermittent inhaled corticosteroids (ICS) plus as-needed short-acting beta-agonists (SABA) therapy or as-needed concomitant ICS and SABA therapy in mild persistent asthma.

The update focused on six topics: intermittent ICS, add-on long-acting muscarinic antagonists, fractional exhaled nitric oxide, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty. The Agency for Healthcare Research and Quality conducted related systematic reviews, looking at 475 studies published from March to April 2017.

Critical outcomes included asthma exacerbations (defined as either systemic corticosteroid use or asthma-specific ED visits or hospitalizations), asthma control, and health-related quality of life. Other outcomes included asthma symptoms, rescue medication use, and composite measures of exacerbations that combined systemic corticosteroids, asthma-specific ED visits, and asthma-specific hospitalizations. The update was published Dec. 3 by JAMA.

Recommendations include the following:

  • Therapy for intermittent asthma (SABAs for rescue therapy) did not change from the previous guideline. For mild persistent asthma, the guideline recommended either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy.
  • For both daily and as-needed therapy, formoterol (a long-acting beta-agonist [LABA]) in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is preferred for moderate persistent asthma requiring low- or medium-dose therapy. A short-term increase in the ICS dose alone is not recommended for worsening symptoms.
  • In individuals whose asthma is not controlled by ICS-formoterol therapy (moderate-severe persistent asthma), add-on long-acting muscarinic antagonists are recommended.
  • Fractional exhaled nitric oxide testing is recommended for diagnosis and monitoring symptoms, but not by itself.
  • Mitigating allergens is recommended only for patients with exposure and relevant sensitivity or symptoms. It should be allergen-specific and include multiple strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy.
  • Sublingual immunotherapy is not recommended specifically for asthma, and bronchial thermoplasty is not recommended as part of standard care.

An accompanying editorial stated that use of ICS on an as-needed basis guided by symptoms for patients with mild or moderate persistent asthma is an important change from previous guidelines. It also noted practical challenges to the recommendation of single maintenance and reliever therapy (SMART) for mild persistent asthma.

“A crucial practical consideration related to the implementation of both an as-needed ICS for mild persistent asthma and SMART for more severe asthma requiring daily ICS-LABA therapy is that at present, the medication plans of many US payers cover only 1 inhaler per month for ICS or ICS-LABA combination inhalers,” the editorial stated. “This limitation must be eliminated, without any requirements for individual prior approval, for these recommended treatment approaches to be widely adopted.”