New GINA guidelines focus on management of mild asthma
Due to the apparent risk of adverse outcomes of disease and adverse events (AEs) associated with short-acting beta-agonists (SABA), the Global Initiative for Asthma (GINA) 2019 guideline recommends that all patients with mild asthma should receive symptom-driven or regular low-dose inhaled corticosteroid (ICS)−containing controller treatment.
“Patients with apparently mild asthma, defined as the presence of asthma symptoms less than weekly in the previous 3 months, are still at risk for adverse outcomes such as near-fatal asthma [16 percent] and death due to asthma [15−20 percent],” said Dr Fanny Ko of the Department of Medicine and Therapeutics, Chinese University of Hong Kong (CUHK), at the Advances in Medicine 2019 conference organized by CUHK. [Allergy 2007;62:591-604]
“Inhaled SABA therapy has been the first-line treatment for asthma for the past 50 years despite its association with AEs such as decreased bronchoprotection, rebound hyperresponsiveness, decreased bronchodilator response, increased allergic response, increased eosinophilic airway inflammation, higher risk of emergency department presentation, and higher risk of death,” she added. [Am J Respir Crit Care Med 2000;161:1459-1464; Respir Med 2000;94:767-771; Ann Allergy Asthma Immunol 2012;109:403-407]
In its 2019 guideline, GINA no longer recommends SABA-only treatment for step 1. All adults and adolescents with asthma are now recommended to receive symptom-driven or regular dose ICS-containing controller treatment to reduce the risk of serious exacerbations. [https://ginasthma.org/pocket-guide-for-asthma-management-and-prevention/]
“In addition, daily ICS is no longer listed as a step 1 treatment option because this strategy is associated with a high probability of poor adherence among this group of patients who do not experience symptoms often,” said Ko.
For step 2, the current guideline recommends daily low-dose ICS or as-needed low-dose ICS plus long-acting beta-agonist (LABA) therapy. Another treatment option is leukotriene receptor antagonists.
Other changes in the new guideline include the use of low-dose ICS/LABA, medium-dose ICS/LABA, and high-dose ICS/LABA combination therapy for steps 3, 4 and 5, respectively.
“Clinicians are also recommended to refer to the pocket guide on difficult-to-treat and severe asthma for further information,” said Ko. [https://ginasthma.org/severeasthma/]
“The pocket guide about difficult-to-treat and severe asthma includes a decision tree about assessment and management of adults and adolescents with uncontrolled asthma or exacerbations despite step 4 or step 5 treatment. The revised pocket guide also includes the use of the newly approved anti-interleukin 4 [IL-4] alpha, dupilumab, and the extension of biologic treatment trial to 6−12 months if response to initial therapy is unclear,” she added.
The changes in current recommendations are based on evidence from the SYGMA 1 and SYGMA 2 trials, which demonstrated that as-needed budesonide/formoterol was superior to terbutaline in well-controlled asthma (SYGMA 1) and equivalent to budesonide maintenance twice daily for annual rate of severe exacerbations (SYGMA 2). [N Engl J Med 2018; 378:1865-1876; N Engl J Med 2018;378:1877-1887]
“A recently conducted randomized, open-label controlled trial on mild asthma patients [n=675] also showed that patients who received as-needed albuterol had higher annualized exacerbation rates compared with those given as-needed budesonide/formoterol or maintenance budesonide plus as-needed albuterol [0.400 vs 0.195 and 0.175],” added Ko. [N Engl J Med 2019;380:2020-2030]