In recent years, it has become increasingly clear that asthma is more heterogeneous than previously believed, with patients representing a range of disease phenotypes that require different treatment approaches. To reflect this shifting perspective and other developments in the field, the National Asthma Education and Prevention Program published focused updates to their asthma management guidelines in the December 2020 issue of the Journal of Allergy and Clinical Immunology.1
“Since the most recent Guidelines for the Diagnosis and Management of Asthma (EPR-3) was released in 2007, there has been substantial progress in understanding asthma diagnosis, management, and treatment,” said Michelle M. Cloutier, MD, professor of pediatrics and medicine at the University of Connecticut School of Medicine in Farmington and chair of the Expert Panel Working Group that developed the updated document.2
The panel used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework to rate the certainty of evidence supporting each recommendation, and they solicited public input to help guide the decision to update the guidelines as well as topic selection. Focus groups included people with asthma, caregivers, and health care providers. The systematic reviews used to inform the recommendations were conducted by the Agency for Healthcare Research and Quality (AHRQ).
The 19 resulting recommendations are grouped by 6 priority topic areas as shown below; the strength of each recommendation (strong or conditional) and the certainty of the supporting evidence (low, moderate, or high) are noted for each item. Of the 6 topic areas, 2 — fractional exhaled nitric oxide (FeNO) testing and bronchial thermoplasty — are new additions to the guidelines.
Recommendation 1 (conditional; moderate). For patients aged 5 years or older with an uncertain asthma diagnosis based on history, clinical findings, and spirometry, or if spirometry cannot be accurately performed, the panel recommends the use of FeNO testing to augment the evaluation. FeNO testing for individuals younger than 5 years of age is not recommended as the associated evidence is inconclusive.
Recommendation 2 (conditional; low). FeNO testing is also recommended to facilitate asthma management and ongoing monitoring (in conjunction with other data) for patients aged 5 years and older when there is uncertainty regarding therapy selection, response monitoring, or dose adjustment. This applies to the use of anti-inflammatory therapies and not biologics except for omalizumab.
Recommendation 3 (strong; low). The panel recommends against the use of isolated FeNO testing for assessment of asthma control and severity or to predict exacerbations in patients aged 5 years and older, as it should only be integrated into the ongoing monitoring and management strategy.
Recommendation 4 (strong; low). FeNO testing is not recommended for prediction of future asthma development in patients aged 0 to 4 years with recurrent wheezing, as it has not been found to be reliable for this purpose.
Indoor Allergen Mitigation
Recommendation 5 (conditional; low). The panel recommends against indoor allergen mitigation efforts as part of the overall asthma management plan for patients (of all ages) who do not have sensitization or symptoms related to indoor allergens.
Recommendation 6 (conditional; low). For those individuals who do have confirmed symptoms to such allergens, a multicomponent allergen-specific mitigation intervention is recommended.
Recommendation 7 (conditional; low). For patients with sensitization or symptoms related to exposure to cockroaches and rodents, the use of integrated pest management is recommended alone or as part of a multicomponent mitigation intervention.
Recommendation 8 (conditional; low). For those with sensitization or symptoms related to dust mite exposure, impermeable pillow/mattress covers are recommended only as part of a multicomponent intervention, not as a single-component intervention.
Intermittent Inhaled Corticosteroids
Recommendation 9 (conditional; high). For patients aged 0 to 4 years who have recurrent wheezing (lifetime history of ≥3 episodes or 2 within the past year) that appears to be triggered by respiratory tract infections with no symptoms between infections, the panel recommends initiating a short course of daily ICS at the onset of infection with SABA for quick relief as needed, instead of as-needed SABA rescue therapy alone.
Recommendation 10 (conditional; moderate). For patients aged 12 years and older with mild persistent asthma, the panel recommends either daily low-dose ICS and SABA as needed, or ICS and concomitant SABA as needed. Evidence is insufficient for patients aged 5 to11 years, thus this recommendation does not apply to this age group.
Recommendation 11 (conditional; low). For patients aged 4 years and older with mild to moderate persistent disease who would likely adhere to daily ICS treatment, the panel recommends against a short-term increase in ICS dose in response to an increase in symptoms or a reduction in peak flow.
Recommendation 12 (strong; high certainty for ages 12 years and older, moderate certainty for ages 4 to 11 years). For patients aged 4 years and older with moderate to severe persistent disease, the panel recommends ICS-formoterol (single maintenance and reliever therapy [SMART]) in a single inhaler as both daily controller and reliever therapy instead of higher-dose ICS as daily controller therapy along with SABA for quick relief or the same-dose ICS-LABA as daily controller therapy with as-needed SABA for quick relief.
Recommendation 13 (conditional; high). For patients aged 12 years and older with moderate to severe persistent disease, the panel recommends SMART for both daily controller and reliever therapy vs higher-dose ICS-LABA as daily controller therapy with as-needed SABA.
Long-Acting Muscarinic Antagonists
Recommendation 14 (conditional; moderate). For patients aged 12 years and older with uncontrolled persistent asthma, the panel recommends against the use of LAMA as an add-on therapy to ICS controller therapy compared to LABA added to ICS.
Recommendation 15 (conditional; moderate). While adding LABA to ICS is preferentially recommended, the panel does recommend adding LAMA to ICS vs continuing ICS alone for patients who are unable to use LABA.
Recommendation 16 (conditional; moderate). For patients aged 12 years and older with uncontrolled persistent asthma despite the use of ICS-LABA, the panel recommends adding LAMA to ICS-LABA vs continuing ICS-LABA only.
Immunotherapy in the Treatment of Allergic Asthma
Recommendation 17 (conditional; moderate). For patients aged 5 years and older with mild to moderate allergic asthma, the use of subcutaneous immunotherapy (SCIT) as adjunctive treatment is recommended if the patient’s disease is “controlled at the initiation, build-up, and maintenance phases of immunotherapy.” Optimal asthma control should be achieved before administration of SCIT to minimize the associated risk of systemic reactions.
Recommendation 18 (conditional; moderate). For patients with persistent allergic asthma, the panel recommends against the use of sublingual immunotherapy (SLIT) to manage asthma. However, in those taking SLIT for comorbid allergic rhinitis with or without conjunctivitis, this therapy may also reduce symptoms of allergic asthma and could be considered.
Recommendation 19 (conditional; low). For patients aged 18 years and older with persistent disease, the panel recommends against the use of bronchial thermoplasty in routine asthma care because of the small benefit-to-risk ratio and uncertainty of long-term outcomes.
The topic areas pertaining to indoor allergen reduction and ICS use are especially important for primary care clinicians, according to Dr Cloutier. The latter “marks a major shift in the treatment of individuals with moderate persistent asthma with the use of an inhaled corticosteroid and formoterol together in a single inhaler for both daily and as-needed use.”
The guidelines “also describe what the expert panel felt were important points for the primary care community to make with patients as part of a shared decision-making process,” Dr Cloutier stated. In addition, the new document contains a section entitled “Limitations and research gaps” that highlights remaining research needs and suggests ways that researchers can strengthen the certainty of the evidence they are developing.
Disclosures: As noted in the paper, Dr Cloutier disclosed that a family member was employed by Regeneron. The panel did not discuss any products by Regeneron.
1. Expert Panel Working Group Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC); Cloutier MM, Baptist AP, et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immun. 2020;146(6):1217-1270. doi:10.1016/j.jaci.2020.10.003
2. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, National Institutes of Health; August 2007.