You're listening to The Drug Report on ReachMD, hosted by Linda Bernstein, Pharm.D., Clinical Professor on the Volunteer Faculty of the School of Pharmacy, University of California, San Francisco.
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Asthma is a major, global public health problem and results in excess morbidity, mortality, and economic costs due to lost productivity. According to the Centers for Disease Control and Prevention, more than 25 million Americans have asthma representing 7.7 percent of adults and 8.4 percent of children. Adolescents aged 11-21 years accounted for over 4.5 million cases in 2018. Asthma has been increasing since the early 1980s in all age, sex and racial groups.
A special online JAMA communication dated December 3 reports on the 2020 Asthma Guideline Update from the National Asthma Education and Prevention Program, aimed at the management of asthma in adolescents and adults. The guidelines are updated with evidence-based recommendations.
Six selected topics that were part of the National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3) were identified as focus areas as part of a formal needs assessment conducted in 2014 and were last updated in 2007. An expert panel was convened in 2018 to update the asthma guidelines. In 2020 the expert panel published the selected topics update. The 6 topics chosen for updating included intermittent inhaled corticosteroids (ICSs); add-on long-acting muscarinic antagonists (LAMAs); fractional exhaled nitric oxide measurement as a biomarker for asthma diagnosis, management and monitoring response to therapy; indoor allergen mitigation strategies; safety and efficacy of subcutaneous and sublingual immunotherapy; and bronchial thermoplasty. The group of 19 asthma content experts, including primary care clinicians, dissemination and implementation experts, and health policy experts conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by the panel to develop 19 new recommendations using the Grading of Recommendations Assessment, Development, and Evaluation platform, also known as the GRADE method. The 17 recommendations for individuals aged 12 years or older were reported in this Special Communication.
From the over 20,500 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (i.e., as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.
The authors reported that the 2020 Asthma Guideline Update had several limitations. A further updated search of the literature was not conducted past 2018 because, in keeping with the GRADE approach that the panel used, in addition to a systematic literature search, it would have required reconvening the expert panel to review the new articles, develop new evidence profiles and evidence to decision tables, discuss the new material, and have a formal vote. This would have further delayed release of the update. Nevertheless, a recent review of the pharmacologic management of asthma published in 2020 is consistent with the pharmacotherapy recommendations in this update. Second, there was the low frequency with which validated outcome measures were used consistently in research studies as recommended by the 2012 Asthma Outcomes Workshop. Absence of these measures reduced the certainty of evidence for many of the outcomes, which altered the strength of the recommendations. Study participants were incompletely characterized especially regarding allergen mitigation interventions in which the allergic status of participants was often not reported or included. Study design concerns included risk of bias, small sample size, and limited information about the harms and benefits of interventions if used in clinical and community settings. Finally, the guideline update was also limited by the focus on 6 priority topics and was not a complete revision of the guidelines. Advances in current knowledge about asthma treatment, especially asthma biologic treatment, demand an update that was not possible given the charge of the expert panel.
The report concluded that asthma is a common disease with substantial human and economic impact worldwide. While no cure or established means of prevention exists, effective treatment is available. The authors stated that “Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.”
For The Drug Report, I’m Pharmacist, Dr. Linda Bernstein.
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