When new clinical care guidelines are issued, it often can take years before they are widely inculcated among practicing physicians. However, in the case of new asthma care guidelines issued in 2020, Brigham and Women’s Hospital has been implementing the recommended new treatment approaches for several years.
Developed by the National Asthma Education and Prevention Program (NAEPP), the 2020 Focused Updates to the Asthma Management Guidelines revises previous guidelines from 2007. Among the revisions is a redefinition of agents that can be used to provide immediate, short-term relief of symptoms. Instead of the stepwise approach recommended previously, the new guidelines recommend the use of inhaled corticosteroids (ICS)/formoterol, or as-needed concomitant short-acting beta2-agonist (SABA) with ICS, as preferred to or on equal footing with SABA alone.
Elliot Israel, MD, director of clinical research at the Lung Center and co-director of the Severe Asthma Program at Brigham and Women’s Hospital, is a member of NAEPP and served on the coordinating committee that oversaw the efforts of NAEPP’s scientific committee, which developed the guidelines. He recently published an article in the Journal of Allergy and Clinical Immunology to address the practical issues clinicians may face as they implement the updated guidance.
“My Brigham colleagues and I conducted seminal studies on the as-needed use of asthma controllers as part of an integrated approach to escalating asthma therapy, going back to a 2005 study published in New England Journal of Medicine and a 2012 study published in JAMA,” he said. “As a result, we have years of experience showing that we can achieve equivalent levels of asthma control by directing patients to use ICS on an as-needed basis — whenever they would typically use their reliever medications — instead of twice daily, as typical controller protocols have suggested.”
Guidance for Clinicians Treating Patients with Asthma
Dr. Israel’s article reviews several issues that may confront clinicians as they attempt to incorporate the new recommendations into their treatment of patients with asthma, including:
- How to treat patients whose oral steroid bursts have decreased after doubling or quadrupling their ICS at the first sign of deterioration
- How to help patients understand and comply with concomitant ICS/SABA treatment
- How to weigh whether ICS/formoterol can be used as a reliever therapy at step 2 of the treatment process
- When treating patients with insurance restrictions, whether mometasone/formoterol can be used as an alternative to budesonide/formoterol and whether clinicians can prescribe two cannisters per month of the combination therapy
- How to address potential patient confusion around using SABA as a reliever if they are still symptomatic and need to move up to more intensive maintenance therapy
- When to consider continued use of long-acting muscarinic antagonist as adjunctive therapy in step 6 of the treatment process
- How to resolve inconsistencies between the new NAEPP guidelines and guidelines from the Global Initiative for Asthma
In the article, Dr. Israel also discusses the use of biologics for severe asthma patients, noting that while biologics are appended in step 5 and step 6 therapy, the NAEPP guidelines do not offer detailed guidance on their use. He suggests that in view of the rapid changes in the asthma evidence base and the introduction of biologic therapies, frequent and comprehensive updating of the guidelines should be supported.
“The Brigham has been on the leading edge of using biologics to treat asthma for several years,” Dr. Israel said. “This has literally transformed patients’ lives and is another good example of how the Brigham’s Lung Center delivers the latest innovations in prevention, diagnosis and treatment to help people with asthma control their disease.”