Background
Guidelines for asthma were first released in the US in 1991 by the National Heart, Lung, and Blood Institute, which were then updated in 2007. In 2020, an expert panel published a selected topics update to the 2007 guidelines, focusing on 6 topics:
- intermittent inhaled corticosteroids (ICS)
- add-on long-acting muscarinic antagonists (LAMAs)
- fractional exhaled nitric oxide (FeNO) measurement as a biomarker for asthma diagnosis, management and monitoring response to therapy
- indoor allergen mitigation strategies
- safety and efficacy of subcutaneous and sublingual immunotherapy
- bronchial thermoplasty
Before moving on to the ICS nitty gritty, think about how these recommendations compare and contrast with the 2020 GINA guidelines (discussed in a prior blog post!)
Focusing on ICS…
Question: What is the comparative effectiveness of intermittent ICS compared to no treatment, pharmacologic therapy, or non-pharmacologic therapy in children aged 0-4 years with recurrent wheezing?
- Recommendation: In children ages 0-4 years with recurrent wheezing triggered by respiratory tract infections and no wheezing between infections, the Expert Panel conditionally recommends starting a short course of daily ICS at the onset of a respiratory tract infection with as-needed SABA for quick-relief therapy compared to as-needed SABA for quick-relief therapy only. (Conditional recommendation, high certainty of evidence)
- Short course = 7-10 days
- 3 RCTs found this approach resulted in a 33% relative risk reduction in exacerbations requiring systemic steroids
Question: What is the comparative effectiveness of intermittent ICS compared to ICS controller therapy in individuals aged 5 years and older with persistent asthma?
- Recommendation: In individuals ages 12 years and older with mild persistent asthma, the Expert Panel conditionally recommends either daily low-dose ICS and as-needed SABA for quick-relief therapy or as needed ICS and SABA used concomitantly. (Conditional recommendation, moderate certainty of evidence)
- Recommendation: In individuals ages 4 years and older with mild to moderate persistent asthma who are likely to be adherent to daily ICS treatment, the Expert Panel conditionally recommends against a short term increase in the ICS dose for increased symptoms or decreased peak flow. (Conditional recommendation, low certainty of evidence)
Question: What is the comparative effectiveness of ICS with LABA used as both controller and quick-relief therapy compared to ICS with or without LABA used as controller therapy in individuals aged 5 years and older with persistent asthma?
- Recommendation: In individuals ages 4 years and older with moderate to severe persistent asthma, the Expert Panel recommends ICS-formoterol in a single inhaler used as both daily controller and reliever therapy compared to either higher-dose ICS as daily controller therapy and SABA for quick-relief therapy or the same-dose ICS-LABA as daily controller therapy and SABA for quick-relief therapy. (Strong recommendation, high certainty of evidence for ages 12 years and above, moderate certainty of evidence for ages 4 to 11 years)
The SMART thing to do!
Two blinded RCTs (n = 5,481) compared single maintenance and reliever therapy (SMART) to higher-dose ICS-LABA in individuals with asthma ages 12 years and older.
- SMART reduced the relative risk of exacerbations by 25% (high certainty of evidence)
- SMART also resulted in statistically significant reductions in corticosteroid use but had no significant effect on asthma quality of life or asthma control
- Of note, the only approved LABA for SMART is formoterol because of its rapid onset and higher maximum daily dose
Also of note, the recommended alternate therapy of maintenance ICS-LABA with SABA as quick-relief therapy does not need to be changed if it is providing adequate control.
Blog post based on Med-Peds Forum talk by Julia Ding, PGY4