One significant change will affect adults and children ages 4 or older with moderate to severe persistent asthma who are using daily controller inhalers. According to the updated guideline, people in this group should now use a single inhaler containing both an inhaled corticosteroid and a bronchodilator daily as a preventive medication and for quick relief during an asthma attack. (Previously they would have been using two separate inhalers — one containing a corticosteroid as a daily controller therapy and one with a bronchodilator for emergency relief during an asthma attack.) “The inhaler use recommendation is going to have a huge impact,” says Edward Brooks, MD, professor of pediatrics and the chief of pediatric immunology and infectious disease at UT Health in San Antonio, Texas, and a member of the expert panel that worked on the new guidelines. Research reviewed in preparation of the new guidelines suggests this change could help patients better manage asthma over the long term and reduce emergency room visits. Another new recommendations is to start inhaled steroids at the onset of colds in infants and children if they are wheezing. Michael Schatz, MD, an allergist-immunologist in the department of allergy at Kaiser Permanente Medical Center in San Diego and past president of the American Academy of Allergy, Asthma, and Immunology, who was a member of the expert panel that drafted the new guidelines, notes that infants and children under age 5 commonly have wheezing during respiratory infections, which is considered a form of asthma. “It can get pretty severe,” says Dr. Schatz. With starting inhaled steroids sooner, research showed you can often reduce the severity of those flare ups and reduce the need for oral cortisone medicines, according to the new guidelines. “A lot of doctors were already doing that, but there was never a definitive recommendation based on definitive data in prior guidelines,” Schatz says. The topics addressed in the new guidelines were selected based on there being a substantial enough amount of new evidence to warrant updated treatment guidelines. The Agency for Healthcare Research and Quality (AHRQ) conducted the systematic review of evidence that was used by a panel of asthma specialists, general medical providers (such as pulmonary and allergy specialist and family and internal medicine physicians), and health policy experts to develop the new recommendations. The new guidelines include updated recommendations for six topic areas. Here are those six topic areas and some of the new recommendations Brooks and Schatz say will be most significant:
1. Tests to Measure Inflammation in the Lungs
A fractional exhaled nitric oxide (FeNO) test can help doctors determine the level of inflammation in the lungs, says Dr. Brooks. While doctors have used this method for some time, the expert panel’s analysis of the data confirmed its usefulness. “This is a rigorous review of how effective that diagnostic technique is for telling us how much inflammation, therefore how should we modify therapy for asthma,” Brooks says.
2. Management of Indoor Allergy Triggers for Asthma Mitigation
The panel issued recommendations about management of indoor allergens (such as dust mites and pets in homes) in asthma control. The research reviewed for this topic included things like how people should eliminate allergic asthma from the home, says Brooks.
3. Inhaler Use
Currently, many individuals with moderate to severe persistent asthma are prescribed one inhaler containing corticosteroids to be used daily to control inflammation and another inhaler containing bronchodilators to be used as a rescue inhaler to provide quick relief during an asthma attack. “The rescue inhaler has an immediate effect whereas people don’t feel the controller inhaler (containing corticosteroids) working, so they tend not to use it,” says Brooks. According to the new guidelines, people with this type of asthma (moderate to severe persistent asthma) should use a combination inhaler (one with a corticosteroid, like formoterol, and a bronchodilator) as a daily controller medication and as a quick-relief medication in the event of an asthma attack. Doctors knew that the inhaled steroids were effective but also knew that many people were not using their daily medication. Now the hope is that more patients will use the inhaler because they’ll feel the immediate effect of the bronchodilator, but they’re also getting the anti-inflammatory effect that is going to help over the long-term, Brooks explains. Schatz calls the recommendation a big departure from what was the standard of care, but one that should improve outcomes. Research shows that using the combination inhaler can help people better control their asthma, Schatz explains. “When you [use the combination therapy], you end up having less asthma episodes, exacerbations, and attacks.”
4. Whether or Not to Add-on Medications for Better Asthma Control (Beyond Inhaled Corticosteroids)
According to Schatz, a new recommendation is to add a different type of bronchodilator, called long-acting muscarinic antagonists (LAMAs), that has been shown to help in patients who are not doing well enough on inhaled corticosteroids and long acting beta agonists (LABAs) alone. He explains that for a large number of people, using inhaled corticosteroid and LABAs will control their asthma well. “But then there’s a subset for whom that doesn’t work, and for them, one of the options at that point is adding in a LAMA,” says Schatz. This recommendation applies to people 12 and older with uncontrolled persistent asthma.
5. Use of Immunotherapy (Particularly for Kids With Asthma and Severe Allergies)
“Use of allergy immunotherapy can benefit asthma, particularly in children,” says Brooks. “If someone has allergies, we know that it affects their asthma and the evidence is pretty strong that this therapy is effective at slowing the progression of asthma.” According to Brooks, a child with severe allergies will tend to progress to have worse asthma, and the evidence shows that if you treat those allergies with immunotherapy, it does help them long term with their asthma.
6. A Risky Procedure That Could Help With Severe Asthma: Bronchial Thermoplasty
Bronchial thermoplasty involves putting a thin tubelike instrument down into the lungs and heating them up to reduce inflammation. “This relatively newer therapy for very severe asthmatics is a somewhat high-risk and invasive technique where you heat up the bronchial tubes under anesthesia,” says Brooks. It does show some benefit, but the risks for complications (such as bleeding in the lungs and temporary worsening of symptoms) are high, he explains. The new guidelines conditionally recommend against using the procedure unless people do not have other appropriate options and are willing to take the risks that come along with it.
What’s Missing, What Might Be Next?
There were some topics — such as biologic medications, which have been approved for use in people with asthma — that were not included, but that clinicians need more guidance on, says Myron Zitt, MD, associate professor of clinical medicine at State University of New York at Stony Brook and director of the adult allergy clinic at Nassau University Medical Center. (Dr. Zitt was not involved in the development of the new guidelines.) “Since the early 2000s, we’ve had biologics that we can use for severe asthma.” The committee that developed the guidelines did consider biologics as a topic to include in this update, but after the review of available research, decided there was not enough evidence at this time to make specific recommendations. Another topic that Zitt identified as one that should have been included was better identifying and tailoring treatment for different types of asthma. Beyond asthma severity, asthma also differs in terms of environmental triggers and clinical presentation (phenotype) and underlying mechanisms (endotype). Some medications work better in certain types of asthma, but not others, and guidance is lacking on how to treat asthma with different characteristics, Zitt says. “Not all asthma is the same.” Schatz notes the steering committee considered the topic, but felt there wasn’t enough information at this time to make recommendations. But it’s definitely worth considering in the future, he adds. Access to care is another area that could be address down the line, says Brooks. He also notes that a lot of the studies did not address the effectiveness of some of these treatments in certain racial groups. “That’s a huge gap,” says Brooks.
What’s the Bottom Line if You (or Your Child) Has Asthma?
Whether you’ve had asthma for decades or you or your child was recently diagnosed there are changes in these guidelines that could affect you, says Brooks. Look through the new asthma management guideline and touch base with your doctor to see how the new guidelines can help you better manage your asthma. “I would recommend that everyone contact their physician and ask: ‘How is this going to affect my asthma management? What is in here that is going to make a difference that is going to help me better manage my asthma?’” suggests Brooks.
