NHLBI Updates Asthma Tx Guidelines

New guidelines from the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI) — the agency’s first update since 2007 — take account of new management options including single maintenance and reliever therapy (SMART) and long-acting muscarinic antagonists (LAMAs).

As has long been standard practice, the foundation for drug therapy remains a stepwise approach, with inhaled corticosteroids used as needed.

For patients 12 and over with mild persistent asthma, short-acting inhaled corticosteroids and bronchodilators should be used as needed, rather than daily, and a short course of inhaled corticosteroids should be used along with as-needed inhaled short-acting beta-agonist (SABA) agents for children under 4 with recurrent wheezing triggered by respiratory tract infections, according to Michelle Cloutier, MD, of UConn Health in Farmington, Connecticut, and colleagues.

SMART, including corticosteroids and formoterol, should be used daily and as-needed for people with moderate to persistent asthma, 4 years and up, according to the revised guideline, published in the Journal of Allergy and Clinical Immunology and JAMA.

Patients who cannot use long-acting beta-agonists (LABA), or whose asthma remains uncontrolled with the use of corticosteroids and LABA, should receive add-on LAMA therapy as well, according to the guidelines.

Along with recommendations on allergic asthma interventions, bronchial thermoplasty, and fractional exhaled nitric oxide (FeNO) tests, these guidelines represent the first update to the NAEPP recommendations since 2007.

“Since that time, we’ve made really substantial progress in understanding how to treat asthma both in children and adults,” Cloutier said during a telephone press conference. “The new guidelines reflect some of these new approaches.”

These guidelines serve as a “welcome update,” said Stephanie Lovinsky-Desir, MD, MS, of Columbia University Irving Medical Center in New York City and JAMA associate editor George T. O’Connor, MD, MS, of Boston Medical Center, in an accompanying editorial in JAMA.

However, one practical consideration related to the new guidelines for as-needed inhaled corticosteroids and SMART is that many U.S. payers only cover one inhaler per month, Lovinsky-Desir and O’Connor noted.

“This limitation must be eliminated, without any requirements for individual prior approval, for these recommended treatment approaches to be widely adopted,” they wrote.

In the new guidelines, FeNO is also recommended as an adjunct to asthma diagnosis and management, but it is not recommended to be used alone as a means of monitoring disease severity.

However, there is an absence of data on FeNO thresholds to guide adjustments in therapy, Lovinsky-Desir and O’Connor indicated. Plus, results can be falsely high or low depending on whether patients recently ingested certain foods or have conditions like obesity. It also requires specialized equipment and longer visits, making it difficult to implement in primary care settings.

“[D]iverting more asthma management to specialists could have unintended consequences of increasing health disparities, especially in communities where marginalized populations have reduced access to subspecialty care,” Lovinsky-Desir and O’Connor wrote.

The guidelines do not recommend bronchial thermoplasty, an outpatient procedure that reduces muscle associated with airway constriction in asthma patients, except under special circumstances such as clinical research.

Assessments of allergen exposures are still recommended in everyone who has asthma. However, patients with asthma who do not have allergies or symptoms when exposed to allergens should not receive routine environmental home interventions, according to the guidelines.

For those who do have allergies or symptoms with exposure, the guidelines recommend a multi-pronged approach rather than a single intervention, although the benefits of many approaches still remain small, Cloutier indicated.

Patients who have sensitization or symptoms related to exposure to dust mites are recommended to get impermeable pillow and mattress covers as part of a multicomponent approach, and individuals with allergies to pests are recommended to get pest management services alone or along with other interventions, according to the guidelines.

Because of the individualized nature of these recommendations and the number of visits needed to make an allergy reduction plan, this portion of the guidelines also “points in favor of specialty care,” Lovinsky-Desir and O’Connor wrote.

“It is likely that certain exceptions exist, such as finding a new home for a household pet to which a patient is allergic, although the expert panel did not comment on scenarios such as this,” they added.

Lastly, patients 5 and up with mild to moderate allergic asthma are recommended to get allergy shots along with standard drug therapy, but oral immunotherapy is not recommended in the updated guidelines.

This set of recommendations does not address the use of monoclonal antibody-based biologics to treat severe asthma or phenotypic-based strategies for treating asthma, likely in part because it did not include evidence published after October 2018, Lovinsky-Desir and O’Connor wrote.

“Non-allergic phenotypes of asthma receive little attention, likely because of limited clinical trials that address specific management strategies for non-eosinophilic asthma phenotypes [like] exercise-induced [or] neutrophilic [asthma],” they wrote.