Asthma Guideline Update Aims to Improve Care, Shared Decisions

January 13, 2021, 12:46 pm News Staff — For the first time in more than a decade, the federal government has updated its guidance on the diagnosis, management and treatment of asthma.

2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was published in the Journal of Allergy and Clinical Immunology and posted on the National Heart, Lung, and Blood Institute’s website in December. The updates provide family physicians and other clinicians with new information that will allow for improved care and enhance the shared decision-making process with patients.

“These are evidence-based, rigorously developed guideline updates that for the family physician will influence how we treat mild and persistent asthma in more patient-centered ways,” said Kurt Elward, M.D., M.P.H., a family physician with Sentara Family Medicine at Belvedere in Charlottesville, Va., and a clinical professor in the Department of Family and Community Medicine at Virginia Commonwealth University, Richmond, who served on the expert panel working group and participated in the analysis and discussion of the recommendations.

“The updates have been a while in coming, and reviewing these are worth the time,” Elward added. “While some of the topics may seem more specialty oriented, our patients may be faced with decisions on these and family physicians can have a reliable resource to which they can refer.”

The updated guidance is especially important in light of the ongoing COVID-19 pandemic. According to the CDC, moderate to severe asthma may put people at increased risk of developing severe illness from COVID-19, and may lead to higher incidence of pneumonia and acute respiratory disease.

Story Highlights

The CDC estimates that nearly 25 million people in the United States had asthma in 2018, the last year for which data were available. Of those, approximately 5.5 million were children. Asthma has also shown to be more prevalent in Black and American Indian/Alaska Native individuals than in white individuals, and more prevalent in individuals living at or below the poverty threshold based on family income and size.

Synopsis

The updated guidance is the result of collaboration between the NAEPP and its participating organizations, the Agency for Healthcare Research and Quality, individual medical experts and the general public.

Altogether, the guidelines contain 19 recommendations focused on six areas. Specifically, the guidance addresses

inhaled corticosteroids when needed in infants and young children with recurrent wheezing or in individuals 4 years and older with persistent asthma;
as-needed inhaled corticosteroids plus long-acting beta-agonists, referred to as single maintenance and reliever (SMART) therapy for treatment of mild persistent asthma, and their use for maintenance and as-needed treatment in moderate persistent asthma;
long-acting antimuscarinic antagonists with inhaled corticosteroids for long-term asthma management in individuals 12 years and older with uncontrolled severe persistent asthma;
multiple allergen mitigation strategies to reduce exposure to specific indoor asthma triggers;
subcutaneous or sublingual immunotherapy as an adjunct to standard pharmacotherapy in individuals 5 years and older with mild to moderate allergic asthma;
a limited role for fractional exhaled nitric oxide testing in the evaluation of asthma in infants and young children with recurrent wheezing, and to manage asthma or confirm a diagnosis in certain individuals 5 years and older in whom the diagnosis is unclear; and
bronchial thermoplasty as a potential treatment option only for certain adult patients with persistent asthma who place a low value on harms and a high value on potential benefits.

The report also contains several new features that make it easier for clinicians to discuss asthma management with their patients, such as an implementation guidance section, expanded recommendation summaries and revised stepwise treatment tables.

What Family Physicians Should Know

Of all the recommendations, Elward cited those pertaining to as-needed use of inhaled corticosteroids plus LABA as the most important for family physicians to be aware of. He said that the therapy “allows greater flexibility and even greater effectiveness/risk reduction for patients who do well much of the year, yet can have flares” – a patient population that Elward said some clinicians refer to as intermittent moderate asthmatics.

“These individuals have never had provisions for care in the guidelines,” Elward continued. “It is a very needed addition. This allows flexible dosing of ICS-LABA that has been shown to reduce ER use, lower the potential for medication side effects and improve outcomes. The role of the primary care physician in patient education and a care partnership are essential in making this successful, and family physicians are well-positioned to do this.”

Elward said that overall, several of the updates may affect the way FPs diagnose, manage and treat asthma.

“SMART therapy, as I mentioned, will definitely guide family physicians in new and safer ways to treat many of our patients,” said Elward. “The update’s conclusions on the newer therapies, such as fractional exhaled nitric oxide and bronchial thermoplasty, which were not strongly recommended, will help family physicians counsel patients in considering these modalities.”

Other Resources

In addition to the report, the NHLBI has posted several companion pieces on its website, including

Additional tools and resources are available via the NHLBI’s Digital Toolkit web page.

Elward told AAFP News that the NHLBI is in the process of developing more resources to be published later this year, including asthma action plans that pertain specifically to SMART therapy and tools that can be used for incorporation into EHR records to provide real-time clinical care. He also recommended the NHLBI’s “Learn More Breathe Better” program as a useful resource for patients.