Disclosures: Cloutier reports having a family member employed by Regeneron and is chair of the NAEPPCC Expert Panel Working Group. Kiley is a director at the NHLBI. Please see the paper for all other authors’ relevant financial disclosures.
December 03, 2020
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NIH updates guidance for diagnosis, management, treatment of asthma

Disclosures: Cloutier reports having a family member employed by Regeneron and is chair of the NAEPPCC Expert Panel Working Group. Kiley is a director at the NHLBI. Please see the paper for all other authors’ relevant financial disclosures.
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The NIH has released new recommendations for the diagnosis, management and treatment of asthma in adolescents and adults, the first updates to federal comprehensive asthma guidelines in more than a decade.

“The 2020 focused updates to the asthma management guidelines are intended to help primary care providers, specialists and patients work together to make decisions about the optimal management of their asthma,” James Kiley, PhD, director of the division of lung diseases at NHLBI, part of the NIH, said during a media telebriefing.

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The new clinical practice guideline was based on the best available science, Kiley said, and the NHLBI “supports implementation research to ensure the adoption and use of guidelines all with the goal of improving care for all people with asthma.”

The recommendations are based on systematic reviews conducted by the Agency for Healthcare Research and Quality and input from National Asthma Education Prevention Program (NAEPP) participant organizations, medical experts and the public. The National Heart, Lung and Blood Institute coordinates the NAEPP Coordinating Committee (NAEPCC) and the 19-member expert panel working group that developed the 2020 Focused Updates to the Asthma Management Guidelines: A Report from The National Asthma Education and Prevention Program Experts Panel Working Group.

New recommendations in six areas

“The last update to the guidelines was published 13 years ago. Since that time, we have made really substantial progress in understanding how to treat asthma in both children and adults, and the new guidelines reflect some of these new approaches,” Michelle M. Cloutier, MD, chair of the NAEPPCC Expert Panel Working Group and professor emerita of pediatrics and medicine at UConn Health School of Medicine in Farmington, Connecticut, said during the telebriefing.

The guideline updates focus on six topics for clinical management of individuals aged 12 years and older: new approaches to inhaled corticosteroid (ICS) use, add-on long-acting muscarinic antagonists, indoor allergen mitigation strategies, immunotherapy for allergic asthma, use of fractional exhaled nitric oxide and bronchial thermoplasty surgery.

The recommendations vary by age and disease severity, Cloutier said.

Pharmacologic recommendations

There are five new recommendations that address the use of ICS in individuals with asthma and in combination with other inhaled medications.

The first two recommendations address intermitted ICS use, rather than on a daily schedule. According to Cloutier, this is the first time the guidelines have recommended intermittent ICS therapy. The updates now recommend a short course (7-10 days) of ICS in young children (aged 0-4 years) who wheeze only at the time of a respiratory tract infection, and daily ICS with a short-acting bronchodilator as quick relief and ICS and a short-acting bronchodilator as rescue medication as needed in adolescents and adults with mild to persistent asthma.

The preferred therapy in individuals aged 4 years or older with moderate to severe persistent asthma is formoterol in combination with an ICS in a single inhaler — or, single maintenance and reliever therapy (SMART) — both for daily and as-needed therapy.

A short-term increase in ICS dose for an asthma exacerbation is not recommended.

“Evidence demonstrates that this approach is not effective in individuals who are using their daily therapy,” she said.

The document also details three recommendations for the use of LAMA therapy in individuals aged 12 years or older. In individuals already on an ICS, a long-acting beta agonist is preferred over LAMA. If the individual cannot use the LABA, then LAMA is recommended. If an individual is on an ICS and a LABA but their asthma is not controlled, it is recommended to add a LAMA.

Allergic asthma recommendations

The update also addresses interventions designed to reduce exposure to allergens, with four new recommendations.

“The 2020 update stresses the importance of targeted interventions for individuals with asthma who have allergies to specific allergens or experience allergy or asthma symptoms when exposed to those allergens,” Cloutier said.

The recommendations are as follows:

  • For individuals with asthma but no allergies to indoor allergens or symptoms when exposed to an allergen, environmental intervention in the home is not recommended.
  • For individuals with asthma and specific allergies or symptoms when exposed to specific indoor allergens, multiple strategies to reduce allergens are recommended.
  • For individuals with asthma who are sensitive to dust mites, dust mite-impermeable pillow and mattress covers are recommended as a multicomponent intervention and not a single-component intervention.
  • For individuals with asthma who are allergic to indoor pests and exposed to cockroaches, mice or rats, integrated pest management is recommended to prevent infestation and reduce allergen levels in the home.

Updates concerned immunotherapy and allergy shots with updated recommendations as follows:

  • For individuals aged 5 years or older with allergic asthma, subcutaneous immunotherapy is recommended in conjunction with standard therapy.
  • Sublingual immunotherapy is not supported by current evidence to treat allergic asthma.

Other recommendations

Fractional exhaled nitric oxide testing is helpful in making the diagnosis of asthma in individuals in whom the diagnosis is not certain based on other testing, according to the updates. It is also useful in long-term management of asthma when it is unclear ow to manage it. However, fractional exhaled nitric oxide testing is not useful in assessing asthma control or exacerbation severity, predicting future exacerbations or in young children to predict future asthma development, according to the new updates.

The 2020 focused update does not currently recommend bronchial thermoplasty in adults with persistent asthma, but it may be considered in special circumstances in specific individuals with asthma as part of a research study or patient registry, for example, Cloutier said.

There have also been new features updated in the 2020 asthma guidelines to assist health care clinicians in using the new recommendations and engaging their patients.

In addition, several new features aim to help health care providers and clinicians engage successfully with their patients and families to put the recommendations into practice. For example, implementation guidance sections provide expanded summaries of the new recommendations to quick assist clinicians, indicate to whom the guidance applies, show how to use it in patient care, and list issues to discuss with patients and families, according to an NIH press release. Stepwise treatment tables for asthma management were also updated, according to the release.

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