Asthma management: How the guidelines compare

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doi:doi: 10.12788/jfp.0501

Applied Evidence

Asthma management: How the guidelines compare

J Fam Pract. 2022 November;71(9):392-397 | doi: 10.12788/jfp.0501

By

Tanner Nissly, DO

Jean Moon, PharmD

Jason Ricco, MD, MPH

This quick guide details the similarities and differences between recommendations from the National Asthma Education and Prevention Program and the Global Initiative for Asthma.

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PRACTICE RECOMMENDATIONS

› Consider early initiation of intermittent inhaled corticosteroid (ICS)- formoterol over a short-acting beta-2 agonist for reliever therapy. A

› Start prescribing single maintenance and reliever therapy (SMART) with ICS-formoterol to reduce exacerbation rates and simplify application. A

› Consider FeNO assessment when the diagnosis of asthma remains unclear despite history and spirometry findings. B

› Consider adding a longacting antimuscarinic agent to a medium- or high-dose ICS-LABA (long-acting beta-2 agonist) combination in uncontrolled asthma. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. CDC. Most recent national asthma data. Accessed October 24, 2022. www.cdc.gov/asthma/most_recent_national_asthma_data.htm

2. Akinbami LJ, Santo L, Williams S, et al. Characteristics of asthma visits to physician offices in the United States: 2012–2015 National Ambulatory Medical Care Survey. Natl Health Stat Report. 2019;128:1-20.

3. NHLBI. National Asthma Education and Prevention Program expert panel report 3: guidelines for the diagnosis and management of asthma. NIH Publication 07-4051. 2007. Accessed October 24, 2022. www.nhlbi.nih.gov/sites/default/files/media/docs/EPR-3_Asthma_Full_Report_2007.pdf

4. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2022. Accessed October 24, 2022. https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf

5. NHLBI. 2020 Focused updates to the asthma management guidelines. Accessed October 24, 2022. www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines

6. Lazarus SC, Krishnan JA, King TS, et al. Mometasone or tiotropium in mild asthma with a low sputum eosinophil level. N Engl J Med. 2019;380:2009-2019. doi: 10.1056/NEJMoa1814917

7. Suissa S, Ernst P, Benayoun S, et al. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343:332-336. doi: 10.1056/NEJM200008033430504

8. Suissa S, Ernst P, Kezouh A. Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Thorax. 2002;57:880-884. doi: 10.1136/thorax.57.10.880

9. Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial. Lancet. 2008;372:1065-1072. doi: 10.1016/S0140-6736(08)61448-8

10. Calhoun WJ, Ameredes BT, King TS, et al. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. JAMA. 2012;308:987-997. doi: 10.1001/2012.jama.10893

11. Garg Y, Kakria N, Katoch CDS, et al. Exhaled nitric oxide as a guiding tool for bronchial asthma: a randomised controlled trial. Med J Armed Forces India. 2020;76:17-22. doi: 10.1016/j.mjafi.2018.02.001

12. Honkoop PJ, Loijmans RJ, Termeer EH, et al. Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: a cluster-randomized trial in primary care. J Allergy Clin Immunol. 2015;135:682-8.e11. doi: 10.1016/j.jaci.2014.07.016

13. Peirsman EJ, Carvelli TJ, Hage PY, et al. Exhaled nitric oxide in childhood allergic asthma management: a randomised controlled trial. Pediatr Pulmonol. 2014;49:624-631. doi: 10.1002/ppul.22873

14. Powell H, Murphy VE, Taylor DR, et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomised controlled trial. Lancet. 2011;378:983-990. doi: 10.1016/S0140-6736(11)60971-9

15. Shaw DE, Berry MA, Thomas M, et al. The use of exhaled nitric oxide to guide asthma management: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176:231-237. doi: 10.1164/rccm.200610-1427OC

16. Stam J, Souren M, Zweers P. The onset of action of formoterol, a new beta 2 adrenoceptor agonist. Int J Clin Pharmacol Ther Toxicol. 1993;31:23-26.

17. Evgenov OV, Liang Y, Jiang Y, et al. Pulmonary pharmacology and inhaled anesthetics. In: Gropper MA, Miller RD, Evgenov O, et al, eds. Miller’s Anesthesia. 8th ed. Elsevier; 2020:540-571.

18. Rodrigo GJ, Neffen H. Efficacy and safety of tiotropium in school-age children with moderate-to-severe symptomatic asthma: a systematic review. Pediatr Allergy Immunol. 2017;28:573-578. doi: 10.1111/pai.12759

19. Global Initiative for Asthma (GINA). Asthma, COPD, and asthma-COPD overlap syndrome (ACOS). 2015. Accessed October 24, 2022. https://goldcopd.org/wp-content/uploads/2016/04/GOLD_ACOS_2015.pdf

CASE

Erica S*, age 22, has intermittent asthma and presents to your clinic to discuss refills of her albuterol inhaler. Two years ago, she was hospitalized for a severe asthma exacerbation because she was unable to afford medications. Since then, her asthma has generally been well controlled, and she needs to use albuterol only 1 or 2 times per month. Ms. S says she has no morning chest tightness or nocturnal coughing, but she does experience increased wheezing and shortness of breath with activity.

What would you recommend? Would your recommendation differ if she had persistent asthma?

* The patient’s name has been changed to protect her identity .

As of 2020, more than 20 million adults and 4 million children younger than 18 years of age in the United States were living with asthma.¹ In 2019 alone, there were more than 1.8 million asthma-related emergency department visits for adults, and more than 790,000 asthma-related emergency department visits for children. Asthma caused more than 4000 deaths in the United States in 2020.¹ Given the scale of the burden of asthma, it is not surprising that approximately 60% of all asthma visits occur in primary care settings,² making it essential that primary care physicians stay abreast of recent developments in asthma diagnosis and management.

Since 1991, the major guidance on best practices for asthma management in the United States has been provided by the National Heart, Lung, and Blood Institute (NHLBI)’s National Asthma Education and Prevention Program (NAEPP). Its last major update on asthma was released in 2007 as the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3).³ Since that time, there has been significant progress in our understanding of asthma as a complex spectrum of phenotypes, which has advanced our knowledge of pathophysiology and helped refine treatment. In contrast to the NAEPP, the Global Initiative for Asthma (GINA) has published annual updates on asthma management incorporating up-to-date information.⁴ In response to the continuously evolving body of knowledge on asthma, the NAEPP Coordinating Committee Expert Panel Working Group published the 2020 Focused Updates to the Asthma Management Guidelines.⁵

Given the vast resources available on asthma, our purpose in this article is not to provide a comprehensive review of the stepwise approach to asthma management, but instead to summarize the major points presented in the 2020 Focused Updates and how these compare and contrast with the latest guidance from GINA.

A heterogeneous disease

Asthma is a chronic respiratory disease characterized by both variable symptoms and airflow limitation that change over time, often in response to external triggers such as exercise, allergens, and viral respiratory infections. Common symptoms include wheezing, cough, chest tightness, and shortness of breath. Despite the common symptomatology, asthma is a heterogeneous disease with several recognizable phenotypes including allergic, nonallergic, and asthma with persistent airflow limitation.

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