Updated Guidelines for the Diagnosis and Management of Asthma – Primary Care Overview

Author: Christine Zink, MD

Guidelines for the diagnosis and management of asthma have recently been updated for the first time since 2007. The National Asthma and Education Prevention Program (NAEPP) Coordinating Committee Expert Panel Report 4 Working Group (EPR-4) was established in 2018 to update the guidelines. The 2020 recommendations use evidence from systematic reviews. The topics include the role of immunotherapy, inhaled corticosteroids, and long-acting muscarinic antagonists in asthma management. The group also discusses the effectiveness of indoor allergen reduction techniques, the utility of fractional exhaled nitric oxide testing, and the risks and benefits of bronchial thermoplasty for asthma management.

The Role of Immunotherapy in the Treatment of Asthma 

  • Takeaway – Both SCIT and SLIT reduce the use of long-term asthma control medications in patients under 18 years old.

Allergen immunotherapy is a disease-modifying treatment that helps to desensitize a person to specific allergens. Immunotherapy is administered subcutaneously or sublingually. Often, the treatment is commonly known as allergy shots. The U.S. Food and Drug Administration approves immunotherapy for house dust mites, 5-grass, Timothy grass, ragweed, and bee or wasp venom to treat allergic symptoms and modify asthma progression.

In the new 2020 guidelines, the EPR-4 group finds that both subcutaneous and sublingual immunotherapy, also known as SCIT and SLIT, reduce the use of long-term asthma control medications in people under age 18. Although the evidence is not as robust, the group also finds that these therapies improve life quality, reduce the need for quick-relief medication, and improve forced expiratory volume (FEV1). There is not enough evidence for the group to determine whether SCIT and SLIT reduce the need for health care utilization. They also were not able to conclude any differences between SCIT versus SLIT. Both forms of treatment are beneficial for children and adolescents with asthma.

It is important to note that local and systemic allergic reactions to allergen immunotherapy are common, but life-threatening events, such as anaphylaxis, are sporadic. With subcutaneous therapy, people might experience urticaria, swelling, redness, or pain at the injection site. For those who use sublingual therapy, reactions can include oral itching and gastrointestinal upset. People treated with immunotherapy should be monitored for 30 minutes after administration to look for these adverse reactions. After administering the first dose in the office, future doses are safe to be given at home.

  1. Intermittent Inhaled Corticosteroids and Long-Acting Muscarinic Antagonists for Asthma

  • Takeaway 1 – Patients age 12 years and older with persistent asthma have fewer asthma exacerbations, hospitalizations, and emergency department visits if they use combination daily inhaled corticosteroids plus a long-acting muscarinic antagonist or a long-acting beta-agonist.
  • Takeaway 2 – Patients age 12 years and older with persistent asthma should use SMART therapy instead of standard control plus short-acting quick relief therapy. SMART therapy reduces asthma exacerbations, hospitalizations, and emergency department visits.

Current stepwise guidelines for poorly-controlled persistent asthma patients include adding daily inhaled corticosteroids to the treatment regimen. Depending on the severity of acute symptoms during an asthma exacerbation, a short-acting beta-agonist with systemic corticosteroids is recommended. However, researchers have been looking for ways to better control persistent asthma, prevent exacerbations, and limit the need for rescue medications. It is essential to limit systemic corticosteroid use due to adverse effects.

The EPR-4 group finds several additions to the current management guidelines. First, people with poorly-controlled persistent asthma often require adjunctive therapy with inhaled corticosteroids. The first-line adjunctive therapy is a long-acting beta-agonist, such as formoterol. However, research shows that adding a long-acting muscarinic antagonist, such as tiotropium, to inhaled corticosteroids provides the same benefit as adding a long-acting beta-agonist. Patients aged 12 years and older who use daily inhaled corticosteroids should also use a long-acting muscarinic antagonist or a long-acting beta-agonist to decrease asthma exacerbations, hospitalization risk, and emergency department visits. Researchers also discuss triple therapy’s utility with inhaled corticosteroids, a long-acting beta-agonist, and a long-acting muscarinic agonist. Although triple therapy seems to improve respiratory measures, it is not associated with a lower risk of asthma exacerbations.

Researchers also evaluated using single maintenance and reliever therapy (SMART) as an alternative to the current daily control therapy with inhaled corticosteroids with or without a long-acting muscarinic antagonist or long-acting beta-agonist in conjunction with a short-acting beta-agonist as rescue therapy. SMART therapy recommends using inhaled corticosteroids and a long-acting beta-agonist together as daily control therapy and quick-relief rescue therapy. The EPR-4 group finds that patients age 12 years and older with persistent asthma who use SMART therapy reduce their risk for asthma exacerbations, hospitalization, and emergency department visits compared to those who use inhaled corticosteroids alone or in conjunction with a long-acting beta-agonist as control therapy and a short-acting beta-agonist for immediate relief. This effect seems to be apparent in children age 5–11 years, but the lack of studies limits the group’s ability to recommend SMART therapy for this age group. It is important to mention that the specific medications used in almost all included studies to create these recommendations were budesonide and formoterol.

Finally, the group also finds that treating children less than five years old with intermittent inhaled corticosteroids rather than a short-acting beta-agonist during a respiratory tract infection with wheezing reduces the risk of worsening symptoms that require oral steroids.

Gain further insight into the most relevant recommendations in our 2020 Focused Updates to the Asthma Management Guidelines, and discover how to incorporate them into your primary care practice.

  1. Effectiveness of Indoor Allergen Reduction in Management of Asthma

  • Takeaway – The use of HEPA vacuums in conjunction with other allergen reduction interventions might improve an asthmatic’s quality of life. However, there is insufficient evidence to recommend specific indoor allergen reduction strategies.

Controlling environmental factors that contribute to asthma symptoms and exacerbations is an essential component of overall management. Researchers evaluated multiple systematic reviews, meta-analyses, randomized-controlled trials, and non-randomized controlled interventional studies that appraised allergen removal interventions including acaricide, or dust mite pesticide use, air purification systems, carpet removal, high-efficiency particulate air filtration (HEPA) vacuum use, mattress cover use, mold removal, pest control, and pet removal. They find that evidence to support a single indoor allergen intervention strategy is lacking. It is challenging to determine whether these interventions decrease asthma symptoms since there is much heterogeneity between the studies. When used in combination, some interventions show improvement in some asthma outcomes, but results are different for each intervention, and they are not consistent. The only indoor intervention that tends to show improved quality of life with moderate strength evidence is HEPA vacuum used in conjunction with other allergen reduction interventions. The EPR-4 group concludes that more research is needed to show clinically meaningful differences in indoor allergen interventions.

  1. Effectiveness and Safety of Bronchial Thermoplasty in Management of Asthma

  • Takeaway – At this time, there is uncertainty about the benefits versus harm in regular bronchial thermoplasty for people with persistent asthma.

Bronchial thermoplasty is a new outpatient treatment modality for patients with persistent asthma. A specific amount of radiofrequency energy is delivered to the airway to heat and cause structural changes to the smooth muscle. The procedure is usually given as three treatments three weeks apart. Since this approach is new, there is limited available literature on its utility. While the studies show a trend toward improved quality of life, the statistical significance of using bronchial thermoplasty with standard asthma care compared to standard asthma care alone is not clinically significant. Additionally, the strength of the evidence is low. The results are similar when bronchial thermoplasty with standard asthma care is compared to a sham bronchoscopic procedure with standard asthma care. The EPR-4 group also finds significantly more adverse events in patients who undergo bronchial thermoplasty, including worsening asthma symptoms, respiratory infections, hemoptysis, and more frequent hospitalizations. At this time, there is uncertainty about the benefits versus the harm in regularly offering bronchial thermoplasty.

The Clinical Utility of Fractional Exhaled Nitric Oxide in Asthma Management

  • Takeaway – The FeNO test moderately helps diagnose asthma, predict future asthma exacerbations, and monitor treatment effectiveness and adherence.

The FeNO (fractional expired nitric oxide) test measures the amount of nitric oxide in a person’s breath to determine if there is underlying lung inflammation related to atopy. The test is quick, noninvasive, and can be done in an outpatient office.

Researchers assessed the role of using this test for diagnosis, treatment, and monitoring of asthma. They find that the FeNO test is moderately helpful in diagnosing asthma. The test is modestly more accurate in diagnosing asthma in people who are not on steroids, children ages 5–18, and nonsmokers. They also find that the FeNO test helps clinicians monitor whether patients are either compliant or responding to asthma treatment, and helps clinicians manage asthma symptoms to reduce the frequency of exacerbations. As would be expected, the specificity of an asthma diagnosis increases as the FeNO cut-off level is raised from 20 ppb to 40 ppb.

The FeNO levels do not correlate with the severity of an acute asthma exacerbation. Although a few studies have been done to assess FeNO testing’s utility in children ages 0–4 years, there is still insufficient evidence to determine if these tests’ results reliably predict a future asthma diagnosis in young children.

Highlights

  • Both SCIT and SLIT reduce the use of long-term asthma control medications in patients under 18 years old.
  • Patients age 12 years and older with persistent asthma have fewer asthma exacerbations, hospitalizations, and emergency department visits if they use combination daily inhaled corticosteroids plus a long-acting muscarinic antagonist or a long-acting beta-agonist.
  • Patients age 12 years and older with persistent asthma should use SMART therapy instead of standard control plus short-acting quick relief therapy. SMART therapy reduces asthma exacerbations, hospitalizations, and emergency department visits.
  • The use of HEPA vacuums in conjunction with other allergen reduction interventions might improve an asthmatic’s quality of life. However, there is insufficient evidence to recommend specific indoor allergen reduction strategies.
  • At this time, there is uncertainty about the benefits versus harm in regularly offering bronchial thermoplasty for people with persistent asthma.
  • The FeNO test moderately helps diagnose asthma, predict future asthma exacerbations, and monitor treatment effectiveness and adherence.

Pri-Med and Learn More Breathe Better℠, a program of the National Heart, Lung, and Blood Institute (NHLBI), launched a two-part CME podcast series to inform primary care clinicians on the updates to the asthma management guidelines.

Find out the important changes to the recommendations and how these changes can improve the diagnosis, treatment, and management of patients with asthma.

Resources

Rice JL, Diette GB, Suarez-Cuervo C, Brigham EP, Lin SY, Ramanathan M Jr, Robinson KA, Azar A. Allergen-Specific Immunotherapy in the Treatment of Pediatric Asthma: A Systematic Review. Pediatrics. 2018 May;141(5):e20173833.

Sobieraj DM, Baker WL, Nguyen E, et al. Association of Inhaled Corticosteroids and Long-Acting Muscarinic Antagonists With Asthma Control in Patients With Uncontrolled, Persistent Asthma: A Systematic Review and Meta-analysis. JAMA. 2018;319(14):1473–1484.

Sobieraj DM, Weeda ER, Nguyen E, et al. Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis. JAMA. 2018;319(14):1485–1496.

Leas BF, D’Anci KE, Apter AJ, Bryant-Stephens T, Lynch MP, Kaczmarek JL, Umscheid CA. Effectiveness of indoor allergen reduction in asthma management: A systematic review. J Allergy Clin Immunol. 2018 May;141(5):1854-1869.

D’Anci KE, Lynch MP, Leas BF, Apter AJ, Bryant-Stephens T, Kaczmarek JL, Umscheid CA, Schoelles K. Effectiveness and Safety of Bronchial Thermoplasty in Management of Asthma. Comparative Effectiveness Review No. 202. (Prepared by the ECRI Institute–Penn Medicine Evidence-based Practice Center under Contract No. 290-2015-00005-I.) AHRQ Publication No. 18-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2017.

Wang Z, Pianosi PT, Keogh KA, Zaiem F, Alsawas M, Alahdab F, Almasri J, Mohammed K, Larrea-Mantilla L, Farah W, Daraz L, Barrionuevo P, Morrow AS, Prokop LJ, Murad MH. The Diagnostic Accuracy of Fractional Exhaled Nitric Oxide Testing in Asthma: A Systematic Review and Meta-analyses. Mayo Clin Proc. 2018 Feb;93(2):191-198.