New Guidelines for Asthma Management

Michelle M. Cloutier, MD

As asthma continues to have no cure or established means of prevention, new recommendations were made for how best to treat the disease in adolescents and adults.

An expert panel of 19 asthma content experts, primary care clinicians, and experts in dissemination and implementation and health care policy used systematic reviews to develop evidence-based recommendations for 6 topics: intermittent inhaled corticosteroids (ICSs), add-on long-acting muscarinic antagonists (LAMAs), fractional exhaled nitric oxide (FeNO) measurement as a biomarker for asthma diagnosis, management and monitoring response to therapy, indoor allergen mitigation strategies, safety and efficacy of subcutaneous and sublingual immunotherapy, and bronchial thermoplasty.

Michelle M. Cloutier, MD, and the team reviewed 20,572 nonduplicated articles and sources and 475 relevant publications were included in the 6 systematic reviews.

One change to the guidelines with important implications for patients and the care team is the recommendation for use of ICSs on an as-needed basis guided by symptoms for patients with mild or moderate persistent asthma. For mild asthma, the guideline conditionally recommended either a regular daily ICS with an as-needed inhaled SABA or use of both an inhaled SABA and an ICS as-needed when symptoms occur. For moderate asthma, there was a strong recommendation for a daily maintenance regimen of an ICS combined in a single inhaler with formoterol plus extra doses of the combination ICS-formoterol therapy as needed for asthma symptoms.

Conditional recommendations were made for the use of LAMAs as add-on therapy. The team recommended against adding a LAMA to an ICS compared with adding a LABA to an ICS in individuals at least 12 years old with persistent asthma. They also recommended if a LABA is not used, the prescriber should add a LAMA to ICS controller therapy compared with continuing the same dose of ICS alone. There was also a recommendation to add a LAMA to ICS-LABA therapy compared with continuing the same dose of ICS-LABA therapy.

Cloutier and the investigators made conditional recommendations for the utility of FeNO in asthma diagnosis and monitoring treatment and disease activity. They recommended in individuals at least 5 years old for whom the diagnosis of asthma was uncertain to use FeNO measurement as an adjunct to the evaluation process. There were also recommendations to add FeNO measurement as part of an ongoing asthma monitoring and management strategy that includes frequent assessments. A strong recommendation was made to not use FeNO measurement in isolation to assess asthma control, predict future exacerbations, or to assess exacerbation severity.

Further, conditional recommendations were made for allergen reduction strategies in the management of asthma, including not using allergen mitigation interventions as part of routine asthma management in those with asthma who did not have sensitization to specific indoor allergens or who did not have symptoms related to exposure to specific outdoor allergens.

For the role of subcutaneous and sublingual immunotherapy in the treatment of allergic asthma, there was a recommendation to use such immunotherapy as an adjunct treatment to standard pharmacotherapy in individuals whose asthma was controlled at the initiation, buildup, and maintenance phases of immunotherapy. It was also conditionally recommended to not use bronchial thermoplasty.

The updated guidelines summarized new recommendations for the long-term management of adolescents and adults with asthma and “should be helpful for clinicians who provide care for patients with asthma in the US and around the world,” Stephanie Lovinsky-Desir, MD, MS, and George T. O’Connor, MD, MS, wrote in an accompanying editorial.

The guideline, “Managing Asthma in Adolescents and Adults,” was published online in JAMA.