In December 2020, the National Heart, Lung, and Blood Institute (NHLBI) released focused updates to its asthma management guidelines for both children and adults. According to Shahid I. Sheikh, MD, FCCP, of Nationwide Children’s Hospital/The Ohio State University, the updates include many changes to conventional thinking about how to best manage asthma.
“These updates were long overdue, as the last full asthma guidelines in the United States were published in 2007,” Dr. Sheikh said. “The guidelines focus on updated information on the best ways to treat asthma based on the current evidence. However, certain aspects of the changes are different from how physicians are used to treating asthma.”
Dr. Sheikh will chair a plenary session, New Focused Updates in Asthma Management Guidelines (EPR-4): Data Analysis and Justifications, on Wednesday at 9:15 am CT that is designed to help participants understand the rationale behind a few of the updates.
Dr. Sheikh will open the session with a discussion surrounding updates on the use of intermittent inhaled corticosteroids (ICS), inhaled steroids for asthma control, and will also briefly focus on single maintenance and reliever therapy (SMART) for asthma control.
SMART therapy is perhaps the most controversial part of the updates, according to Dr. Sheikh.
“This is a very new concept and will require a lot of education at both the physician and patient levels,” he said.
Muhammad Adrish, MD, MBA, FCCP, of Baylor College of Medicine, will follow with a discussion on the use of ICS and long-acting beta-2-agonists (LABA) both as daily maintenance and as needed for acute flare-ups in more detail.
Next, Nauman A. Chaudry, MD, FCCP, of Virginia Commonwealth University, will talk about the rationale behind the use of long-acting muscarinic antagonists (LAMA) in asthma control. This area of management is also changing, Dr. Sheikh said. For example, in individuals with asthma that is not controlled by ICS plus LABA therapy alone, adding a LAMA to an ICS with or without LABA is recommended.
Finally, Mariam Louis, MD, FCCP, of the University of Florida College of Medicine, will present updates on use of fractional exhaled nitric oxide and allergy control in asthma care.
The other important consideration related to these NHLBI-focused updates, Dr. Sheikh noted, is that many of the recommendations related to medication usage are not approved by the US Food & Drug Administration (FDA).
“The studies done to support these recommendations were done with medications of different strengths or delivery systems, which we do not use in the United States,” he said. “It will be difficult to get these approved through the FDA unless studies are done with the doses used or pharmaceutical companies come up with equivalent doses for approval by the FDA.”
Another possible barrier is that many insurance company payers will only approve coverage for one inhaler a month. It is also not clear if physicians will be comfortable with patients using multiple inhalers every month for symptom control.
“If you use ICS plus LABA for asthma for both daily maintenance and acute flare-ups, then patients will need more than one inhaler a month,” Dr. Sheikh said. “If payers won’t approve such use, it will be a significant cost to the patient, which will deter adherence.”
Overall, Dr. Sheikh said that these updates are good and overdue with significant data that suggest patients may achieve better asthma control with these approaches. However, he emphasized that one important take-home message is, “If patients are well controlled on their current therapies, there is no need to switch.”
This session is supported in part by a scientific and educational grant from Vertex Pharmaceuticals Incorporated.
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