Should Asthma Care Shift Away From Control and Severity Steps?

Despite significant advances in asthma treatment in the past decades, the disease is still poorly controlled in an estimated 50% of patients, and causes thousands of deaths each year in the United States.^1,2 Suboptimal asthma control can be partly attributed to poor treatment adherence, highlighting the need for interventions to address this issue. In addition, a growing number of experts point to a need for changes in the approach to asthma management.^3,4

In a commentary published in the Journal of Asthma, Luis J. Nannini, MD, of Rosario National University in Argentina, questions the usefulness of the concept of asthma control and the effectiveness of the stepwise treatment approach recommended in the Global Initiative for Asthma (GINA) treatment guidelines.³ Although GINA established these concepts in 1997, there remains a “substantial gap between GINA objectives and outcomes, and a rigid step-wise approach focused on control may be hindering rather than helping asthma management,” noted Dr Nannini.

He and others have suggested that a continuum of care or a treat-to-target approach would be more favorable alternatives for patients, as both strategies “focus on treatable traits, instead of using maintenance or reliever medications concepts.” Dr Nannini also notes the potential utility of focusing on reducing asthma activity vs achieving disease control.³

We interviewed Megan Conroy, MD, chief fellow in pulmonary and critical care medicine at The Ohio State University Wexner Medical Center in Columbus, to further discuss needed changes in asthma care.

Dr Nannini states that it may be time to shift from using the GINA severity steps to a “continuum of care approach where patient-adjusted therapy would comprise both a controller and reliever in a single inhaler.” What are your thoughts about this?

The changes in GINA 2019 should result in increased exposure to inhaled corticosteroids for mild asthmatics.⁵ The recommendations introduce a major shift in the paradigm of asthma treatment, away from beginning with short-acting beta agonist reliever therapy towards the use of inhaled corticosteroid in combination with fast-acting reliever therapy. GINA 2019 states a preference for single maintenance and reliever therapy, with benefits to the patient of a single inhaler with resultant ease of use and the ability for patient-adjusted therapy as needed. However, the lack of Food and Drug Administration approval for an inhaled corticosteroid/fast-acting beta agonist combination inhaler in the United States results in practical barriers for patients – namely, cost.

Dr Nannini’s proposed improvements to the concept of “control” and a more strictly graded initiation of the stepwise approach to treatment would likely provide primary care physicians with more explicit guidance on the appropriate initiation of therapy.

Whether we call the early and increased use of inhaled corticosteroids in asthma treatment a disease-modifying, treat-to-target approach or something else, these concepts highlight the importance of rebranding the emphasis of asthma treatment to both our colleagues and our patients. As clinicians, we must find an effective way to communicate this major shift in treatment focus to our patients, or we will continue to see the overuse of short-acting beta agonist reliever therapy, underuse of inhaled corticosteroids, and the resultant poor outcomes. As these changes permeate clinicians’ practices, we, as a community, should agree on a terminology for this approach that stresses the clear knowledge that asthma is a disease of inflammation, with treatment first and foremost targeting this pathophysiology.

What other changes are needed in the current model of standard asthma treatment?

In applying any guideline, recommendation, or model of care to a patient, the approach must be individualized between physician and patient. As asthma treatment options become more complex, we cannot overlook the “basics.”

While GINA continues to stress the assessment of asthma co-factors such as gastroesophageal reflux disease, allergy/atopy, environmental exposures, chronic rhinosinusitis, obesity, and others, the aggressive management of these factors is often neglected by treating physicians with a myopic focus on step-wise approach to inhaler therapy. However, not all asthma control is obtained through inhalers – the aggressive treatment of co-factors is often necessary to achieve freedom from asthma symptoms. Additionally, clinician assessment of inhaler technique and adherence is underutilized. As asthma treatment evolves with many more therapeutic options, these “bread and butter” considerations become even more important. 

What are remaining needs in this area in terms of education and research?

For GINA 2019 changes to be embraced by clinicians and enacted by patients — with the goal of improved control and reduced airway inflammation — we need to educate both patients and non-pulmonary physicians about the necessity of treating asthma as a disease of inflammation.

Regarding research needs, when considering the treatment of severe asthma and the use of biologic therapy, we need better understanding of how to personalize this care. As we phenotype and endotype patients with asthma, we need to determine which of the available medications will be the most effective for any individual patient. How do we switch between these options of biologics, and how do these emerging therapies impact special populations, such as pregnant women with asthma?

References

1. Gruffydd-Jones K, Hansen K. Working for better asthma control: How can we improve the dialogue between patients and healthcare professionals? Adv Ther. 2020;37(1):1-9.

2. Centers for Disease Control and Prevention. Asthma. https://www.cdc.gov/nchs/fastats/asthma.htm Accessed online April 24, 2020.

3. Nannini LJ. Is it time to leave behind the concept of asthma control and severity steps? [Published online November 14, 2019] J Asthma. doi:10.1080/02770903.2019.1690659

4. O’Byrne PM, Jenkins C, Bateman ED. The paradoxes of asthma management: time for a new approach? Eur Respir J. 2017;9;50(3).

5. Global Initiative for Asthma. Global strategy for asthma management and prevention, 2019. Accessed online April 24, 2020.