December 3, 2020
New Asthma Guidelines: For the first time since 2007, the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee, coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), has updated its asthma guidelines.
The full document, 2020 Focused Updates to the Asthma Management Guidelines: A Report from the NAEPP Coordinating Committee Expert Panel Working Group, was published in the December issue of The Journal of Allergy and Clinical Immunology (JACI), an official journal of the American Academy of Allergy, Asthma & Immunology (AAAAI).
“The publication of the 2020 Focused Updates to the Asthma Management Guidelines represents a significant advance in asthma care. The inclusion of implementation guidance and shared decision making will enable providers to assure optimal care for their patients with asthma. I would like to thank Dr. Giselle Mosnaim for her work as the AAAAI representative to the NAEPP Coordinating Committee. In addition, a special thanks to AAAAI members Drs. Robert Lemanske, Michael Schatz, Alan Baptist, Kathryn Blake, and Edward Brooks who served on the NAEPP Coordinating Committee Expert Panel Working Group,” said AAAAI President Mary Beth Fasano, MD, MSPH, FAAAAI.
The newly published asthma guidelines contain updated recommendations that cover the following six different topics:
Fractional Exhaled Nitric Oxide (FeNO) Test
The document lists four recommendations when it comes to FeNO testing. A FeNO test is a way to determine how much lung inflammation is present and how well inhaled steroids are suppressing this inflammation.
FeNO testing is not recommended for children aged 0-4 who experience recurrent wheezing to predict the future development of asthma.
For anyone 5 years and older, FeNO testing recommendations are somewhat different. It is not recommended to use FeNO as the only measurement for asthma control. It is recommended for individuals with asthma symptoms if a diagnosis is uncertain using other testing methods such as spirometry and clinical history. Additionally, for those with persistent allergic asthma, if there is uncertainty in choosing, monitoring, or adjusting asthma treatment therapies based on other methods, the Expert Panel conditionally recommends adding FeNO measurement to help monitor and manage asthma.
Another four recommendations were made regarding allergen mitigation as it relates to asthma. Allergen mitigation interventions are not recommended for individuals with asthma who lack sensitization to specific indoor allergens or who don’t have any indoor allergen symptoms. For those who do have confirmed allergies to indoor allergens, multicomponent allergen-specific interventions are recommended.
The Expert Panel recommends the use of pest management alone or as part of a multicomponent allergen-specific mitigation intervention for individuals with asthma who are exposed and have symptoms related to exposure to pests such as cockroaches and rodents. For those with allergies to dust mites, the new recommendations do not support impermeable pillow/mattress covers alone but only as part of a multicomponent allergen-specific intervention.
Inhaled Corticosteroids (ICS)
ICS are medications used to treat asthma and were the subject of five recommendations. Low-dose ICS is recommended for individuals 12 and older with mild persistent asthma, either daily or as needed along with short-acting beta-agonists (SABA). For those 4 years and older with mild to moderate persistent asthma who adhere to daily ICS treatment, it is recommended that healthcare workers do not increase ICS doses in the short-term due to increased symptoms.
For moderate to severe persistent asthma, it is recommended to use ICS-formoterol in a single inhaler for daily asthma control and as reliever therapy. That recommendation varies slightly depending on the age group. In patients 4 to 11 years, the single inhaler is recommended compared to using a higher-dose ICS for daily controller therapy and SABA for quick-relief. It is also recommended over same-dose ICS-long-acting beta agonists (LABA) as a daily therapy with SABA for quick relief. For those 12 and older, the single inhaler is recommended compared to a higher-dose ICS-LABA for daily therapy and SABA for quick relief.
For children aged 0-4 who have recurrent wheezing due to respiratory tract infections but no wheezing between infections, a short course of daily ICS and as-needed SABA for quick-relief is recommended compared to SABA as-needed only.
Long-acting Muscarinic Antagonist (LAMA)
The document lists three recommendations when it comes to LAMA, which is a class of medications used for COPD that sometimes may be used for asthma.
It is not recommended to add LAMA to ICS therapy, compared to adding LABA to ICS therapy in children 12 and over with persistent, uncontrolled asthma. In the same population, LAMA is recommended to be added to ICS controller therapy if LABA is not used, compared to continuing the same dose of ICS alone. Adding LAMA to ICS-LABA is recommended in this population compared to continuing the same dose of ICS-LABA for uncontrolled asthma.
Two recommendations were released regarding immunotherapy and allergic asthma. The first recommends the use of subcutaneous immunotherapy (SCIT) for individuals 5 years and up as an additional treatment to standard medications in individuals whose asthma is controlled at the initiation, build-up and maintenance phases of immunotherapy.
For those with persistent allergic asthma, the use of sublingual immunotherapy (SLIT) in asthma treatment is not recommended.
Bronchial Thermoplasty (BT)
One recommendation was released regarding BT, a non-drug outpatient procedure developed to treat severe, persistent asthma. This treatment is not recommended for individuals 18 and older with persistent asthma. For those over 18 who are less concerned about potential harms and more concerned with potential benefits, they may consider BT.
Dr. Robert Lemanske, who as previously mentioned is a member of the Expert Panel Working Group that authored the guidelines, provided some context on how they were updated. “The updates were developed using some new approaches compared to those used previously. First, it was not a complete revision but rather a focus on six topic areas that were decided upon initially by a needs assessment committee. Second, it used a new technique of evaluating clinical data called GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Third, was the inclusion of an Implementation Guidance (IG) section for each recommendation.”
He concluded, “The IG section provides further clarification of the population to which the recommendation applies, exceptions, and practical aspects of how to use the recommendation in patient care. At the end of each IG section is a list of issues suggested by the Expert Panel to communicate to patients as part of shared decision making about whether to use the therapy or intervention presented in the recommendation.”
“From the beginning, the 2020 Focused Updates to the Asthma Management Guidelines was designed to help primary care providers, specialists, and patients work together to make decisions about asthma care,” said James P. Kiley, PhD, director of the Division of Lung Diseases at the NHLBI, a part of the NIH. “Our goal was to provide clear summaries about each of the new recommendations, information to share with patients, and updated treatment diagrams.”