New Asthma Guidelines Lessen Emphasis on Daily Inhaler Use

For the first time in more than a decade, the National Institutes of Health (NIH) updated its recommendations for asthma diagnosis and treatment. Most notably, the authors advise using inhaled corticosteroids (ICSs), commonly known as inhalers, on an as-needed basis for patients with mild or moderate persistent asthma.

The December updates were published in the Journal of Allergy and Clinical Immunology. They follow the previously-used four classifications of asthma:

• Step 1: intermittent asthma
• Step 2: mild persistent asthma
• Step 3: moderate persistent asthma
• Step 4: moderate-severe persistent asthma

The guidance recommends “a major change in the treatment of moderate persistent asthma in adolescents and adults." For the first time, the guidance includes how to use long-acting muscarinic antagonists (LAMA), the placement of fractional exhaled nitric oxide (FeNO) testing in asthma diagnosis and monitoring, and using bronchial thermoplasty, according to commentary from one of the authors posted in JAMA.

The recommendations were issued by a panel of 19 experts, including healthcare policy officials and primary care clinicians. They reviewed more than 20,500 sources.

New Asthma Recommendations

The recommendations include updates on many factors ranging from asthma testing to several treatment options. The panel zeroed in on six major topic areas:

• Fractional exhaled nitric oxide testing
• Indoor allergen mitigation
• Intermittent inhaled corticosteroids
• Long-acting muscarinic antagonists
• Immunotherapy in the treatment of allergic asthma
• Bronchial thermoplasty

Fractional Exhaled Nitric Oxide (FeNO) Testing

This test—which measures lung inflammation and the level at which steroids are helping—isn’t recommended in children ages 4 and under who experience recurrent wheezing.

Recommendations differ in those over the age of 5, but they advise against using FeNO as the only gauge of asthma control. It should be used to monitor and manage cases of persistent allergic asthma if doctors and patients are unsure about choosing, monitoring, or adjusting asthma treatment therapies.

Indoor Allergen Mitigation

Experts don’t recommend attempting to decrease an individual’s exposure to allergens in people who lack sensitization to specific indoor allergens or who don’t have any indoor allergen symptoms. Recommendations vary based on the type of indoor allergen, but experts do not recommend solely using impermeable pillow or mattress covers as an intervention.

Intermittent Inhaled Corticosteroids (ICS)

"The new recommended evidence-based guideline for mild-persistent type asthma has now changed," Clifford W. Bassett, MD, an allergist based in New York City, tells Verywell. 

There are two options for managing an individual with mild, persistent asthma. While some patients can use ICS on a regular/daily basis, those who don't need it daily can use their ICS when they are symptomatic and having a flare-up based on specific instructions from their physician. Bassett says it's important to have an assessment of the airway in persistent asthma using exhaled nitric oxide, as that can help tailor asthma management.

The report suggests the following:

• In children ages up to 4 years with recurrent wheezing at the start of a respiratory tract infection, a short (7-10 day) course of daily inhaled corticosteroids along with an as-needed short-acting bronchodilator (such as albuterol sulfate) is recommended.
• Experts don't recommend increasing the regular ICS dose for short periods when symptoms increase or peak flow decreases in people ages 4 and up with mild to moderate persistent asthma who use inhaled corticosteroids daily.
• For people over the age of 4 with moderate to severe persistent asthma, the recommendations favor a single inhaler with ICS and formoterol as both a daily asthma controller and quick-relief therapy.
• Anyone over the age of 12 with mild asthma can use ICS with a short-acting bronchodilator for quick relief. They may use ICS daily or when asthma worsens.

Long-acting Muscarinic Antagonist (LAMA)

These medications are used to treat chronic obstructive pulmonary disease and asthma. The experts don’t recommend adding LAMA to ICS therapy. They recommend adding LAMA to ICS controller therapy if a long-acting beta-adrenoceptor agonist (LABA) is not used in the same population, compared to taking the same dose of ICS only. Adding LAMA to ICS-LABA is recommended in favor of continuing the same dose of ICS-LABA for uncontrolled asthma.

Immunotherapy

The team recommends using subcutaneous immunotherapy (SCIT)—allergy shots—for patients over the age of 5. This is in addition to standard medication in patients whose asthma is controlled at the initiation, build-up, and maintenance phases of immunotherapy. Sublingual immunotherapy (SLIT)—under-the-tongue exposure—should not be used to treat asthma in people with persistent allergic asthma.

Bronchial Thermoplasty (BT)

The team doesn’t recommend this outpatient procedure in people over the age of 18 who have persistent asthma.

Better Asthma Care

“We have known for several years that inhaled steroid treatments are very effective ‘controller’ medications for prevention of asthma symptoms,” Vincent Tubiolo, MD, an allergist in California, tells Verywell. But recent research confirms what many patients already know: just increasing the dose isn’t enough to treat flare-ups. 

“Studies show that a combination of inhaled steroid and ‘reliever’ (preferably a long-acting bronchodilator) used together are more effective than increasing the dose of inhaled steroids,” Tubiolo says. “This type of action plan allows improved control of symptoms and inflammation at the same time.”

“This also limits the side effects, both in the long-term and short-term) of inhaled steroids,” he adds.

Lorene Alba, director of education at the Asthma and Allergy Foundation of America (AAFA), tells Verywell that the previous and updated guidelines recommended taking ICS daily to manage mild-to-moderate persistent asthma. However, studies show that people with asthma may receive the same benefit from using ICS as needed instead of every day, Alba says.

"Patients are more likely to adhere to a medication plan if it is easy to follow," Alba says. "Using both a quick-relief and ICS inhaler at the same time may be easier than trying to remember which medicine to take to daily and which medicine to take as needed."

Daily ICS use can have side effects, so reducing usage can lower unpleasant side effects, Alba says. However, patients should talk with their doctor before stopping or changing the way they take their ICS medications.

Biologics Better for Some Asthmatics

As for what’s next in treating asthma, Tubiolo says there have been many exciting innovations in biologics—products derived from living organisms. Though they can be expensive, the treatments target specific aspects of asthmatic inflammation and are very effective at blocking the disease process. They offer better symptom control and reduce the need for steroid medications that can be harmful, he says.

"There are numerous developments already available for treatment that include disease modifiers that can change asthma at the cellular level,” Tubiolo says. “Several more are being studied and will be available soon. Many of these treatments block the immune signals that worsen the disease and can limit the migration of allergic cells into the airways.”

The result of biologics is better asthma control with less need for steroid medications and fewer side effects, Tubiolo adds. Biologics were not included in the report because evaluating them would have delayed publication, the authors noted.

Alba says there are five biologics available for those living with moderate-to-severe asthma that is not well-controlled on daily inhaled corticosteroids.

"Because biologics target a specific antibody, molecule, or cell involved in asthma, they provide precision therapy," Alba says. "They work by disrupting the pathways that cause swelling in the airways, reducing asthma episodes, emergency room visits and the need for oral steroids."

An asthma specialist can conduct testing to determine if a biologic medicine is a good option for patients.

"More biologics are in development," Alba says. "Since each biologic works differently, having more options for targeted treatments for people with hard to control asthma will be useful."