Around 25% of Mild Asthma Patients Not Given Guideline-Directed Therapy, Despite Updates

Beth A. Zerr, PharmD

Credit: University of Arizona

Around a quarter of individuals that have mild persistent asthma did not receive the guideline-directed therapy urged in updated Global Initiative for Asthma (GINA) and the National Heart Lung and Blood Institute (NHLBI) asthma guidelines, according to new findings.¹

These findings and others resulted from a recent retrospective chart review of asthma patients’ electronic medical records. The investigators, led by Beth A. Zerr, PharmD, from the University of Arizona, noted that GINA and NHLBI updated treatment recommendations for mild asthma in 2019 and 2020, respectively, changing the organizations’ prior short-acting beta-agonist (SABA) monotherapy recommendation.^2,3

The GINA update got rid of SABA entirely and the NHLBI update continued to recommend SABA monotherapy for mild intermittent asthma, but not for mild persistent asthma. Now, the organizations added daily therapy with inhaled corticosteroids (ICS), as recent data on ICS-containing therapy indicated that it lowered hospitalizations from asthma, diminished severe exacerbations, and reduced mortality rates.⁴

“The purpose of this study was to evaluate how many patients with mild asthma were prescribed as needed or daily ICS in addition to as needed bronchodilator per the updated GINA and NHLBI guidelines,” Zerr and colleagues wrote. “In addition, evaluation of incidence of exacerbations in patients with mild asthma, and examination of patient-specific factors that contribute to exacerbations…will also be assessed.”¹

Background and Methods

The investigators noted the guidelines, prior to the 2019 GINA update, deemed SABA monotherapy to be suitable only for the first step of therapy, aimed at mild intermittent asthma or very mild asthma cases. The 2019 changes to GINA’s recommendations suggested that SABA was not useful for any asthma patient, irrespective of their classification of severity.

The change in the NHLBI 2020 updates indicated SABA monotherapy would be for mild intermittent asthma but that it should not be endorsed for mild persistent cases. Specifically, the updated guidelines advocate for ICS alongside as-needed SABA, as-needed ICS-long-acting beta agonist (LABA), or as-needed ICS using as-needed SABA over sole reliance on as-needed SABA.

The research team’s retrospective chart review explored the electronic medical records of those in the large Banner Health IRB healthcare system from July 2021 - July 2022, looking to quantify the prevalence of as-needed or daily ICS and as-needed SABA for those with mild asthma.

The secondary goal of the team was to evaluate exacerbation rates among patients with mild asthma, contrasting individuals adhering to guideline-based treatment versus individuals not following these directives. Additionally, the investigators analyzed other patient factors which could have contributed to exacerbation risk within the realm of mild asthma.

They collected data on patients’ sex, age, payer type, race, and active SABA, ICS, and ICS-LABA prescriptions. They also assessed their diagnosis codes, patient prescriber, name of location, and date.

Findings

Out of the 1,107 eligible study participants, 26% were noted by the investigators as lacking documentation of guideline-directed therapy for cases of mild asthma in the study period time frame. They noted that 74% had been given such therapy, with the difference being 48.7% (95% CI: 45.1 - 52.3%, P < .001).

In their exploration of the secondary aim, the research team reported that among the 161 subjects who had reported exacerbations, a total of 12% had been on guideline-directed therapy, as opposed to 15.4% not on such therapy. Despite this difference (-3.4%) in exacerbation incidence, the difference between the 2 treatment arms was shown not to have reached statistical significance (95% CI: -8 - 1.1%; P = .133).

Additionally, the investigators expressed that factors such as female gender, GERD presence, and patient obesity had been shown to be statistically significant in their link with asthma exacerbations among those in the patient cohort.

“More work needs to be done to increase provider awareness regarding asthma guideline updates in outpatient and inpatient settings,” they wrote. “Lastly, further studies in patients with mild asthma are needed to examine medication adherence, patient satisfaction, and exacerbation rate comparing patients on guideline-directed therapy versus those who are not.”

References

1. ^{Zerr, B.A., Kruse, J.M. & Glover, J.J. Evaluation of adherence to guideline-directed therapy and risk factors for exacerbation in mild asthma: a retrospective chart review. Allergy Asthma Clin Immunol 20, 27 (2024). https://doi.org/10.1186/s13223-024-00888-6.}
2. ^{Global Initiative for Asthma (GINA). GINA Report, global strategy for asthma management and prevention. 2019. https://www.ginasthma.org.}
3. ^{2020 Focused Updates to the Asthma Management Guidelines. National Heart, Lung, and Blood Institute of Health. 2020; Publication No. 20-HL-8141.}
4. ^{Reddel HK, Busse WW, Pedersen S, et al. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study. Lancet. 2017;389:157–66..Yawn BP, Rank MA, Cabana.}