Asthma: Everything you need to know

The last update to national asthma guidelines was in 2007, but a number of recommendations are coming forward that could go into the next set of updates when they are published.

Asthma is the most common chronic childhood disease, affecting approximately 5.5 million children in the United States.¹ Good control of asthma is necessary to preserve lung function and prevent exacerbations, but approximately 40% of all pediatric asthma patients don’t have their condition under control.² There are a number of reasons for this, including nonadherence and inadequate treatment regimens.

The National Asthma Education and Prevention Program published updates to its asthma management recommendations in December 2020.1 The update included focus on:

• use of exhaled nitric oxide,
• control of indoor allergies,
• medications for intermittent wheezing,
• use of long-acting muscarinic antagonists,
• Immunotherapy, and
• bronchial thermoplasty.

Angela Duff Hogan, MD, FAAAAI, FACAAI, FAAP, a member of the American Academy of Pediatrics’ Section on Allergy and Immunology and a practitioner at Children’s Hospital of The King’s Daughters in Norfolk, Virginia, says that updates also need to be made on availability and use of medications.

“Since 2007 there has been numerous medication changes.” Hogan says. “There was a time when we felt all asthmatics should have an inhaled steroid year-round with albuterol to use as needed. But based on research, we know that most patients do not adhere to this regimen.”

Although some medications have been changed or removed like short-acting β-agonists, new ones have been introduced, and the way others are used have changed. One specific change is the use of controller medications. Previously, it was recommended to keep children on inhaled albuterol treatments all year, Hogan said. Now, new guidelines suggest children aged 4 years and younger with recurrent wheezing due to upper respiratory infections stop treatments once the infection or symptoms resolve. The guideline also addresses single-inhaler maintenance and reliever therapy (SMART), which uses inhaled corticosteroids and formoterol for maintenance therapy and rapid symptom relief.

“The new guidelines recommend in children between the ages of 0 and 4 with recurrent wheezing episodes due to viral infections, that inhaled corticosteroids be used with the onset of the upper respiratory infection along with short acting beta agonist (SABAs) and stopped when the symptoms resolve. The new guidelines also talk about SMART therapy. Smart therapy is single maintenance and reliever therapy. It recommends using ICS/formoterol for both reliever therapy and daily therapy,” Hogan explains. “If these guidelines are adopted, it means patients could have 1 inhaler that they use at the beginning of their symptoms if they have milder forms of asthma or daily for rapid relief of symptoms.” An official update to the guidelines likely will include more recommendations, but here are a number of medication changes that may be included.

Bronchodilators

Bronchodilators, or short-acting β-agonists, aren’t used to manage asthma, per se, but can be used for as-needed relief of asthma symptoms. Children with asthma should be treated with a controller medication regimen, according to the Global Initiative for Asthma (GINA).³ Albuterol and levalbuterol are the 2 bronchodilators approved for use in the US. A new generic version of albuterol called ProAir HFA was released in 2020.

Corticosteroids

Low-dose inhaled corticosteroids often are used for maintenance therapy. Some changes to options of this medication class are as follows:

• Pulmicort Flexhaler (budesonide) was approved for children aged 6 years and older.
• QVAR RediHaler (beclomethasone) was approved for children aged 4 years and older. It replaces the former metered dose inhaler.
• Fluticasone propionate HFA and the dry powder inhaler (DPI) can be used in children aged 4 years and older.
• Twisthaler (mometasone) was approved for children aged 4 years and older.
• Fluticasone furoate DPI and mometasone HFA are now available to younger children aged 5 years and older.

Combination therapies

Inhaled corticosteroids and long-acting B-agonists (LABAs) can be used to control chronic inflammation as well as asthma, symptoms. In 2017, the United States Food and Drug Administration (FDA) removed safety warnings for LABAs.

Leukotriene receptor antagonists

For mild asthma or allergy-related or exercise-induced asthma, antileukotriene medications such as montelukast can be helpful. However, the FDA has added a warning to montelukast after behavior and mood changes were noted in some individuals taking this medication. Patients who take montelukast should be monitored for neuropsychiatric changes.

Hogan says the updates will reflect some of the recommendations released in 2019 by GINA, as well as other international organizations that update asthma guidelines each year. One of these recommendations was to stop treating adolescents and adults who have asthma with short-acting β-agonists alone. Instead, patients with mild asthma should receive inhaled corticosteroids for chronic management or symptomatic relief.

In addition, “The recommendations were that sublingual immunotherapy is not recommended in the treatment of asthma, and that subcutaneous immunotherapy should not be used in patients with severe or unstable asthma,” Hogan says.

“In terms of environmental control measures…allergen reduction should only be used in those individuals who have allergen-induced symptoms and sensitization to specific indoor allergens,” Hogan continued. “There is little evidence to support [the idea that] isolated single interventions really make much impact on asthma control, exacerbations, and other relevant outcomes.”

References

1. National Institutes of Health. Accessed March 23, 2021. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines

2. Hogan AD, Mahr TA. Update on pediatric asthma treatment options, doses, label changes. AAP News. July 1, 2020. Accessed March 23, 2021. https://www.aappublications.org/news/2020/07/01/focusasthma070120

3. Reddel HK, FitzGerald JM, Bateman ED, et al. GINA 2019: A fundamental change in asthma management: treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Eur Respir J. 2019;53(6):1901046. doi:10.1183/13993003.01046-2019