Big, Important Changes in Asthma Management Guidelines

Neil Skolnik, MD


February 08, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik.

Today we are going to talk about the 2020 Update to the National Institutes of Health (NIH) asthma guidelines for individuals 12 years and older. I had the privilege to serve as one of the members of the expert group that developed the guidelines, which represent the first update to the guidelines since 2007. There are some very important changes for primary care clinicians to be aware of.

I will emphasize the guidelines' "preferred" approach. The alternative recommendations included in these new guidelines, while important, go beyond the scope of our discussion. In a couple of places, I will mention where the World Health Organization Global Initiative for Asthma (GINA) guidelines differ from the NIH's version.

Let's start with step 1: mild intermittent disease. There is no change from the 2007 asthma guidelines. Short-acting beta-agonist therapy (essentially albuterol) is used as needed. Of note, the GINA guidelines recommend, even for intermittent disease, that a low dose of inhaled corticosteroids (ICS) be added whenever a beta-agonist is used.

Let's move on now to step 2: mild persistent disease. In 2007, an ICS alone was recommended. In the current guidelines, there is a choice of preferred therapy: either ICS alone, while only using albuterol as rescue therapy, or a protocol where we use both ICS and albuterol together, but only when symptoms occur. The GINA guidelines recommend as-needed ICS-formoterol in-combination inhaler as a similar option.

The idea here is that patients benefit from receiving additional ICS when they are experiencing symptoms in order to decrease inflammation and the likelihood of going on to have a full exacerbation.

The advantage of ICS alone is that there are fewer breakthrough symptoms.

The advantage of an as-needed ICS/beta-agonist therapy is that you get the ICS and the beta-agonist only when you need it, thereby receiving a lower total dose of ICS over time with no increase in exacerbations.

For moderate persistent disease (step 3), the 2007 guidelines recommended stepping up from a daily ICS alone to low-dose combination ICS/long-acting beta-agonists (LABA) therapy, while continuing to use albuterol as needed for breakthrough symptoms. The 2020 guidelines — and this is another big change — recommend using daily combination low-dose ICS/formoterol along with as-needed low-dose ICS/formoterol as reliever therapy, thereby increasing the ICS dose in the presence of symptoms. SMART (single maintenance and reliever therapy) has also been used for this purpose. The GINA guidelines recommend the use of any ICS/LABA combination therapy, which is an alternative approach for step 3 disease in the NIH guidelines.

For moderate to severe persistent disease (step 4), the 2020 guidelines recommend daily and as-needed medium-dose ICS/formoterol, with an alternative choice of daily medium-dose ICS/LABA or ICS/long-acting muscarinic antagonist (LAMA), while using with albuterol for breakthrough symptoms.

If the patient is not controlled on daily medium-dose ICS/LABA therapy, we can add a LAMA for step 5 care. LAMAs hadn't been studied yet for asthma treatment back in 2007. Now research suggests that they are an important addition. For some patients, the addition of a LAMA can really make a world of difference.

Remember, for patients with severe asthma, particularly those with frequent exacerbations not controlled with standard therapy, a high dose of ICS/LABA can be used. Furthermore, a whole new class of biologic agents — monoclonal antibodies — can now be prescribed, typically with specialty consultation.

These are big, important changes.

I'm Neil Skolnik, and this is Medscape.

Neil Skolnik, MD, is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington – Jefferson Health. He has published over 350 articles, essays, poems, and op-eds in the medical and nonmedical literature, as well as four medical textbooks and a book of short stories. In addition, he is the host of the American Diabetes Association's monthly Diabetes Core Update podcast. Follow him or direct-message on Twitter: @NeilSkolnik

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