New asthma guide: What doctors should know

Pearl Toh
26 Nov 2020

Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.

The ACG — put up by a panel of 17 local experts from multiple disciplines, including respiratory medicine, emergency medicine, family medicine, paediatrics, and nursing — distilled the best available evidence on asthma into nine concise, evidence-based recommendations (Figure 1) to guide clinicians, especially those in primary care, when making treatment decisions and optimize quality of patient care. [Agency for Care Effectiveness (ACE). Asthma – optimising long-term management with inhaled corticosteroid. ACE Clinical Guidance (ACG), Ministry of Health, Singapore. 2020]
Figure 1: 9 recommendations for asthma management

Figure 1: 9 recommendations for asthma management

The call to regularly assess and proactively manage both symptoms and risk of poor outcomes underlies the overarching theme of the ACG for asthma. In particular, the ACG emphasizes the need to address the underlying pathophysiology — ie, chronic airway inflammation — by means of preventer treatment, particularly a regimen containing ICS.

“Despite the wide availability of ICS, the use of preventers [or controllers] in Singapore is the lowest among eight countries in the Asia-Pacific region, with only one in four patients with asthma aged 12 years using a preventer in the past month,” the panel of experts noted, citing findings from a multinational survey of 3,630 asthma patients in the region. [Respirology 2013;18:957-967]

If not adequately managed in the long term, poor outcomes may ensue, including exacerbations, hospital admissions, and even death.

“However, the degree of chronic airway inflammation does not always correlate with the extent of symptoms,” the experts pointed out. Therefore, it is important to address the underlying airway inflammation, and not just the visible symptoms of asthma.

“While more frequent or intense asthma symptoms are associated with higher risk of poor asthma outcomes, (including exacerbations and hospital admissions), such risk may still exist even if the patient reports minimal symptoms,” they explained.

The issue is further compounded by the fact that many patients have poor perception of asthma control, with 65 percent of patients surveyed in Singapore believing that their condition is under control. In reality, only 14 percent had controlled asthma based on the GINA classification as shown in a regional survey. [Respirology 2013;18:957-967]

Therefore, having a comprehensive assessment of both symptoms and risk of poor outcomes, along with factors that could influence both aspects, is the first step towards personalized management of asthma.  

How to assess

The management goal for asthma is to prevent or minimize symptoms and reduce risk of poor outcomes, wrote the ACG experts.

To attain this goal, symptoms — as well as factors influencing symptoms and risk of poor outcomes — should be regularly assessed, according to the ACG. Factors for risk of poor asthma outcomes that clinicians should look out for include inhaler technique, adherence to treatment, lung function, and relevant comorbidities.

For asthma symptoms, the ACG recommends using validated questionnaires such as ACQ, ACT**, or Childhood-ACT, for assessment. Aspects of asthma symptom to assess include frequency and intensity of symptoms during daytime and night-time, frequency of reliever use to alleviate symptoms, and ability to perform daily activities.

“Consider reviewing asthma management when symptoms are frequent (for example, an average of more than twice a week), when they affect the patient’s ability to carry out daily activities or rest at night, or when there is a change in usual number or intensity of symptoms,” the experts advised.

Influencing factors for both symptoms and risk of poor outcomes are best reflected through the BREATHE acronym for ease of recall and to guide assessment (Figure 2).

Figure 2: BREATHE factors for asthma assessment
(Adapted from ACG 2020 for asthma)

Figure 2: BREATHE factors for asthma assessment (Adapted from ACG 2020 for asthma)

Some of the risk factors listed may also be red flags for more severe asthma outcomes (eg, severe exacerbations or mortality). These factors should therefore be prioritized during assessment, including suboptimal ICS use, no preventer treatment or using up ≥1 canisters of SABA*** within 2 months, having ≥1 exacerbations over the past 1 year, having prior intubation or ICU admission due to asthma, and cigarette smoking or ongoing exposure to second-hand smoke. 

How to manage

Daily ICS remains the mainstay of long-term asthma management, as highlighted in the guideline. This is because ICS addresses airway inflammation and represents the most effective preventer option across the asthma treatment steps — with the most available evidence supporting its protective benefits against exacerbations and mortality in the long term.

In contrast, SABA does not address airway inflammation and its use alone (without a preventer) is discouraged in the ACG, in line with recent updates in GINA#.

“The recommendation not to use SABA alone (without a preventer) for the long-term treatment of patients aged 6 years, even those with infrequent or minor symptoms, is the most significant change in asthma management recently,” the experts highlighted. 

The change was prompted by studies which showed that patients relying on SABA alone for managing asthma had an increased risk of poor outcomes, including need for oral corticosteroids (OCS), visits to emergency department, or hospitalization compared with those using an ICS-containing preventer in addition to SABA as a reliever therapy. [N Engl J Med 2018;378:1865-1876; N Engl J Med 2019;380:2020-2030]

Nonetheless, SABA may still be used as needed for short-term relief of symptoms, but only with ICS use, and never SABA alone.

As the cornerstone of asthma treatment for long term, ICS has been shown to benefit at low doses even in patients with minor or infrequent asthma symptoms. [Lancet 2017;389:157-166]   

“Daily ICS-containing treatment is particularly important for patients at higher risk of poor asthma outcomes (for example, those with frequent or intense symptoms, or those with multiple BREATHE factors),” according to the ACG.

However, some patients may be nonadherent to ICS due to the misconception that ICS use comes with adverse effects (AEs) similar to those observed with OCS. To clear up this misconception, doctors need to educate their patients that the risk of AEs with ICS is much lower than OCS, the experts urged.

To minimize the risk of ICS-related AEs, the ACG suggests optimizing inhaler techniques and using the lowest effective dose possible for ICS.

“ICS-naïve patients usually respond well to initial ICS treatment with daily low-dose ICS,” the experts said. “The decision regarding the choice or adjustment of preventer treatment is mainly guided by asthma symptoms, risk of poor asthma outcomes, and presence of BREATHE factors.”

“However, reliance on a solely symptom-driven approach may limit the achievement of the management goal for asthma,” they added.

If the condition calls for stepping up of treatment — such as in patients who still have intense or frequent symptoms, along with risk of poor outcomes based on BREATHE factors — the ACG recommends adding another drug such as LABA or LTRA## first, rather than increasing the ICS dose. Other options include increasing the frequency or dose of ICS (Table), with closed patient monitoring.  

Table: Stepwise approach to asthma pharmacological treatment for patients ≥12 years;

MART: maintenance and reliever therapy;

^ denotes preventer options with the most evidence available

Table: Stepwise approach to asthma pharmacological treatment for patients ≥12 years; MART: maintenance and reliever therapy; ^ denotes preventer options with the most evidence available

Specialist referral should be considered for step 4 and 5 patients, although referral can be made at any point. In particular, add-on treatment with biologics or low-dose OCS can be considered for step 5 patients, on top of step 4 therapy.

Once asthma symptoms remain well managed for 3–6 months, clinicians can consider stepping down the preventer treatment gradually, to the lowest effective dose. However, the ACG cautioned against stepping down when the risk of exacerbation is expected to be high, for instance during pregnancy, allergy season, illness, or high stress.

“Stopping ICS altogether is not recommended [in asthma patients aged 5 years] as this is associated with increased risk of exacerbations,” the experts added.

When adjusting the preventer treatment, clinicians should discuss with patients the potential risks and benefits and monitor them closely. 

Lastly, patient education on self-management is important and can be carried out with a personalised written asthma action plan. Clinicians should also regularly follow up on all patients by providing long-term scheduled appointments.


*ACE: Agency for Care Effectiveness
**ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test
***SABA: Short-acting beta2 agonist
#GINA: Global Initiative for Asthma
##LABA: Long-acting beta2 agonist; LTRA: leukotriene receptor antagonist

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