2020 Updated Asthma Guidelines: Intermittent inhaled corticosteroids and long-acting muscarinic antagonists for asthma—the latest NAEPP guidelines are SMART!

Asthma management has changed so much in the last 25 years since I began my training pulmonary medicine and set out to be an “asthmatologist.” Back then, all we had were scheduled inhaled corticosteroids (ICSs) bronchodilators, primarily albuterol as a short-acting therapy 4 times per day. Patients often told take 12 puffs (!) of triamcinolone twice daily address inflammation, if things got bad, there was always theophylline try settle down airways. In that era, chronic maintenance corticosteroid use recommended only treatment for severe asthma prevalent despite being known somewhat harmful! Since incremental changes have come approximately every 5 years, new National Education Prevention Program (NAEPP) guidelines published. As time went on saw emergence combinations ICS long-acting ?-agonist (LABA), leukotriene modifiers, our first biologic (ie, omalizumab), which approved 2003 target IgE “allergic asthma.” Progress slowed few thereafter, when 2007 NAEPP emerged,1National ProgramThird Expert Panel Diagnosis Management Asthma. panel report 3: Guidelines diagnosis asthma. Bethesda, Md: Heart, Lung, Blood Institute; Aug 2007. Report no. 07-4051.https://www.ncbi.nlm.nih.gov/books/NBK7232/Google Scholar but rapid field subsequent decade made it impossible keep up. Starting with US Food Drug Administration approval bronchial thermoplasty 2010 tiotropium 2015, evolved completely, development biologics IL-5, IL-5 receptor, or IL-4 receptor. Rather than attacking possible questions emerged, most recent guidelines, decided phased approach dig into some key clinical quandaries. Although recommendations regarding implementation are still desperately needed, right. With many advances evolving quickly excitement surrounding biologics, remained unanswered less asthma, problems almost seemed forgotten its prevalence. These taken delving deeply gathering evidence make informed decisions about important concepts. Among issues addressed updated guidelines2Cloutier M. Baptist A. Blake K. Brooks E. Bryant-Stephens T. et al.Expert Working Group Institute (NHLBI) administered coordinated by Coordinating Committee (NAEPPCC)2020 Focused Updates Guidelines: from Group.J Allergy Clin Immunol. 2020; 146: 1217-1270Abstract Full Text PDF PubMed Scopus (58) Google related as-needed utilization muscarinic agents (LAMAs) such (Table I). these concepts not new, they been extensively studied before 2007, included those hence widely implemented practice patients United States.Table INew ICSs LAMAsAge individual (y)Type asthmaKey recommendationKey LAMA recommendation0-4Recurrent wheezing triggered respiratory tract infection no between infectionsStart short course at onset SABA quick relief>4Mild-to-moderate persistent good adherenceDo short-term increase dose increased symptoms decreased peak flowDo flowModerate-to-severe asthmaUse combination formoterol single inhaler used both controller reliever therapyUse therapy>12Mild low-dose relief concomitantlyUncontrolled asthmaAdd LABA ICS; add cannot usedAdd ICS-LABA Open table tab starting infection, (SABA) young children short-term–increased flare-ups, perhaps strongest individuals aged older moderate-to-severe versus alternatives: either higher-dose plus therapy. This intermittent dosing could “depend individual’s decision (based need, is also ‘as-needed’ ‘PRN (pro re nata)’ dosing, predefined index showing worsening other criterion.”2Cloutier The data long supported this approach, what surprising how recommendation formalized States. suggested schedules may useful settings, insufficient. But anymore. reasons plentiful. First, makes sense. If someone symptomatic, likely underlying inflammation giving additional steroids? Why should response bronchodilator? get problem? Second, paradigm understood past 2 decades,3O’Byrne P.M. Bisgaard H. Godard P.P. Pistolesi Palmqvist Zhu Y. al.Budesonide/formoterol medication asthma.Am J Respir Crit Care Med. 2005; 171: 129-136Crossref (530) Scholar, 4Rabe K.F. Pizzichini Stallberg B. Romero S. Balanzat A.M. Atienza mild-to-moderate asthma: randomized, double-blind trial.Chest. 2006; 129: 246-256Abstract (205) 5Scicchitano R. Aalbers Ukena D. Manjra Fouquert L. Centanni al.Efficacy safety budesonide/formoterol higher budesonide moderate asthma.Curr Med Res Opin. 2004; 20: 1403-1418Crossref (168) endorsed Global Initiative years6Global AsthmaGlobal strategy prevention (2020 update). GINA, 2020.ginasthma.org/wp-content/uploads/2020/04/GINA-2020-full-report_-final-_wms.pdfGoogle outside States time. concerns previously raised so-called SMART (single therapy) owing potential LABAs, part mitigated large studies safety.7Busse W.W. Bateman E.D. Caplan A.L. Kelly H.W. O'Byrne Rabe Chinchilli V.M. Combined analysis trials ?2-agonists.N Engl 2018; 378: 2497-2505Crossref (47) LABA, cost regulatory hurdles exist countries, including States; nonetheless, now pave way consisting eventually become standard care rescue once currently ongoing completed. meantime, let us hope reviews favorably providers payers will adopt policies implement effective more readily. It great see novel based during infections flare-ups reduce exacerbations requiring systemic pediatric populations. concept reducing seems intuitive, excellent over several validating recommendation, mixed growth suppression effects warrant shared making allow best choice particular individual. However, even concern, support fact superior efficacy ease result overall reduced exposure. Another major consideration LAMAs obstructive disease, studied, generally up option why needed guidelines—to message clinicians. who uncontrolled recommends adding addition continuing same combination. too smart, experts recognized beneficial regard control quality life setting. Interestingly, study shown improves lung function does lead significant reduction exacerbations.8Lee L.L. Bailes Z. Barnes N. Boulet L.P. Edwards Fowler once-daily single-inhaler triple (FF/UMEC/VI) FF/VI inadequately controlled (CAPTAIN): double-blind, randomised, phase 3A trial.Lancet 2021; 9: 69-84Abstract (26) against ICS. rationale “adding risk harm, real-world blacks.”9Wechsler M.E. Yawn B.P. Fuhlbrigge Pace W.D. Pencina M.J. Doros G. al.Anticholinergic vs beta-agonist black adults BELT randomized trial.JAMA. 2015; 314: 1720-1730Crossref (44) instance, inform future cited actually said although “among treated ICS, did improve exacerbation compared tiotropium,” study's authors concluded do superiority adjusted rates hospitalizations due felt “no conclusions can reached among receiving [among patients] because prespecified outcome” trial. All said, concern glaucoma urinary retention availability fixed-dose controllers containing (vs lack LAMA) certainly challenging implement. Nonetheless, used, conditionally alone benefits obviously considered here. era personalized medicine, respond one another, would ideal identify predictors therapies treat accordingly. add-on sense, strong data, undoubtedly better strategies remain further research exact formulations, cost-effectiveness, subpopulations thoughtful comprehensive leaves clinicians them, educating evaluating just settings. We decades, need develop finally help guide forward questions. 2020 A GroupJournal Clinical ImmunologyVol. 146Issue 6PreviewThe Institutes Health. designed patient update addresses six priority topic areas determined state science needs assessment, input multiple stakeholders:A rigorous process undertaken evidence-based guidelines. Full-Text Access