2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

Abstract

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders: Fractional Exhaled Nitric Oxide Testing Indoor Allergen Mitigation Intermittent Inhaled Corticosteroids Long-Acting Muscarinic Antagonists Immunotherapy in the Treatment of Allergic Asthma Bronchial Thermoplasty A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality’s (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

Is It Really Feasible to Use Budesonide–Formoterol as Needed for Mild Persistent Asthma? A Systematic Review and Meta-Analysis

“…Although several reviews had evaluated the efficacy of budesonide-formoterol used as needed in patients with mild asthma (Bianco et al, 2020;Cloutier et al, 2020;Papi et al, 2021), it was still not comprehensive. In our meta-analysis, we not only showed that inhaled budesonide-formoterol used as needed may reduce severe exacerbations in patients with mild persistent asthma, but also emphasized that the evidence of budesonide-formoterol used as needed for improving clinically significant difference of symptoms and lung function may be insufficient, which needs to be further confirmed in the future.…”

“…In our meta-analysis, we not only showed that inhaled budesonide-formoterol used as needed may reduce severe exacerbations in patients with mild persistent asthma, but also emphasized that the evidence of budesonide-formoterol used as needed for improving clinically significant difference of symptoms and lung function may be insufficient, which needs to be further confirmed in the future. Different from other reviews (Bianco et al, 2020;Cloutier et al, 2020;Papi et al, 2021), we conducted quantitative analysis of published data of previous literatures, which is helpful for physicians to understand more vividly. It's worth noting that there was a high degree of heterogeneity when comparing multiple outcomes (exacerbation, FEV1, inhaled glucocorticoid dose and adverse events) between the budesonide group and the budesonide-formoterol group in the present meta-analysis.…”

Efficacy and safety of add-on tiotropium in the management of uncontrolled asthma: a patient case series

“…Persistent asthma, a heterogeneous disease characterized by chronic airway inflammation (1,2), is commonly treated with short-acting β 2 -agonists (SABAs), inhaled corticosteroids (ICS), or a combination of an ICS and a long-acting β 2 -agonist (LABA) (3). Additionally, other controller medications include oral corticosteroids (OCS); leukotriene receptor antagonists (LTRAs), long-acting muscarinic antagonists (LAMAs); and anti-immunoglobulin E, anti-interleukin 5/interleukin 5 receptor; and anti-interleukin 4 receptor agents (1).…”

“…The National Asthma Education and Prevention Program (NAEPP) 2020 guidelines recommend that for patients aged ≥12 years with uncontrolled persistent asthma in whom a LABA cannot be used (e.g. the patient is unable to tolerate LABA treatment, LABA is contraindicated, the patient cannot use the inhaler device, or the LABA is unavailable), adding a LAMA to an ICS is an acceptable alternative (2). Furthermore, the NAEPP advocates that for patients in whom asthma is uncontrolled with an ICS-LABA combination, a LAMA may be added, as it offers a small potential benefit (2).…”

“…the patient is unable to tolerate LABA treatment, LABA is contraindicated, the patient cannot use the inhaler device, or the LABA is unavailable), adding a LAMA to an ICS is an acceptable alternative (2). Furthermore, the NAEPP advocates that for patients in whom asthma is uncontrolled with an ICS-LABA combination, a LAMA may be added, as it offers a small potential benefit (2). However, more data are required on the effectiveness of tiotropium and its effect on patients' day-to-day lives (15).…”