National Asthma Guidelines Get First Update in 13 Years

Updated recommendations from the National Institutes of Health’s National Heart, Lung, and Blood Institute in 6 key areas of asthma care are focused on improving diagnosis, management, and treatment.

The guidance, which includes 19 recommendations, was published in Journal of Allergy and Clinical Immunology. It represents the first updates to federal comprehensive asthma management and treatment guidelines in more than a decade.

“The last national guidance on asthma care was published 13 years ago, and since then we’ve made substantial progress in understanding how to treat asthma in children and adults,” Michelle M. Cloutier, MD, professor emerita, University of Connecticut School of Medicine, and chair of the National Asthma Education Prevention Program Coordinating Committee Expert Panel Working Group, said in a statement. “In addition to asthma management varying by age group and disease severity, the preferences and values that individuals with asthma place on different therapies must be considered. The new guidelines reflect some of these new approaches.”

The 6 areas of guidance with updates are:

• Using inhaled corticosteroids when needed for recurrent wheezing or persistent asthma
• Using long-acting antimuscarinic antagonists with inhaled corticosteroids for long-term asthma
• Using allergy shots that contain very small amounts of allergen to treat some people with allergic asthma
• Using 1 or more methods to reduce exposure to indoor asthma triggers
• Using a fractional exhaled nitric oxide (FeNO) test to help manage asthma or help confirm a diagnosis in some patients when the diagnosis is unclear
• Using bronchial thermoplasty to treat selected adults with persistent asthma

The recommendations are based on systemic reviews by the Agency for Healthcare Research and Quality from research published before October 2018. In her foreword to the guidelines, Cloutier noted that there is an “absence of many strong recommendations,” which are those recommendations that clinicians should adhere to almost all the time as standard of care.

“This is not, however, surprising given the variations in asthma phenotypes and endotypes and in the outcomes used in the studies reviewed to develop the recommendations,” she wrote.

While the working group felt there was a lack of sufficient data to develop recommendations for additional areas, it identified another 11 emerging topics that needed to be acknowledged in the update:

1. Adherence
2. Asthma action plans
3. Asthma heterogeneity
4. Biologic agents
5. Biomarkers other than FeNO
6. Classification of asthma severity
7. Long-acting beta-agonist safety
8. Physiological assessments
9. Prevention of asthma onset
10. Role of community health workers in asthma management
11. Step down from maintenance therapy

The topic that received the most attention was biologic agents. At the time that the priority topics and key questions were developed for the update to the guidelines, only 1 biologic agent was available for use in the United States. However, between 2015 and 2017, 4 biologic agents had received approval.

“Ultimately, broad change in clinical practice depends on the uptake, adoption, and implementation of clinical practice recommendations by primary care providers with input from people who have asthma and their families, as well as support from health care systems,” the authors of the guidelines wrote. “This update can serve as a basis to disseminate and facilitate adoption of the asthma recommendations at all levels and to ensure optimal care and equitable outcomes for all individuals with asthma.”

Reference

Cloutier MM, Baptist AP, Blake KV, et al; Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC). 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):P1217-1270. doi:10.1016/j.jaci.2020.10.003