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Guidelines based Management
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So, this last couple of years have really been eventful for asthma. We saw a major focused update from NAEPP, the NIH Export Panel Report 4. GINA, of course, has done tremendous work and updates, living guidelines that are updated every year. And I do recommend reviewing the key recommendations from the focused asthma-managed guidelines. It's fairly recent, so I'm not sure if this would show up on the boards, but I think it's good to be familiar with them. So, goals of asthma management are twofold. Basically, reduce impairment and future risk by optimizing management. And effective asthma management really requires a partnership between the patient and the healthcare team. I'm sharing with you this table from the 2007 NIH guidelines, only because I want to share what was considered components of asthma severity based on frequency of symptoms, nighttime awakenings, rescue inhaler use, activity limitation, lung function, and exacerbations. And this was really in patients who were treatment-naive. But over the years, the concept of asthma control and severity have really evolved. And we now think of asthma severity really as the intrinsic disease severity, and it is estimated by the amount of treatment, the level of treatment required to achieve good control. Whereas asthma control is really a measure of symptoms and risk and clinical impairment. So, they're really two separate things, and we can have a patient who has severe asthma but good control, or patients with mild asthma but are poorly controlled. And the process that I use is to assess asthma control using available questionnaires like Asthma Control Test or ACQ, Asthma Control Questionnaire or the GINA questionnaire, and look at their risk, particularly exacerbations which are not captured by the control questionnaires that go back one to four weeks. And based on this, we determine whether a patient has well-controlled, partly controlled, or uncontrolled asthma. And then we optimize their treatment. And then based on the lowest level of treatment required to meet control, we can assess asthma severity. And I'm sharing this table from 2019 GINA update, which was really a major landmark change, which was really a paradigm shift in management of asthma, where they introduced as-needed inhaled corticosteroid and formoterol in step one and two of therapy, and replaced short-acting beta agonist with as-needed low-dose ICS formoterol. And it's just important to know, and I don't know if this would come up, but just it's important to know that this strategy only works with formoterol, has only been studied with budesonide formoterol, that is Simbacort. And formoterol is really serves well here, mainly because it's fast-acting and long-acting. And there's good evidence to support its use. You know, the rationale is that patients use their inhaler only when they have symptoms. And historically, adherence to a scheduled inhaled steroid is poor. And overuse of short-acting beta agonist is associated with increased risk of death. And even people with mild asthma have exacerbations. So these four large studies, one year duration with over 10,000 patients, showed that as-needed use of ICS formoterol decreased exacerbations versus Shaba alone, and was similar to scheduled ICS, but with much lower steroid exposure. The Geno 2021 guidelines were updated earlier this year, actually just last month, and they split the stepwise therapy into the preferred reliever and an alternate reliever. So there's sort of two parallel pathways, stepwise to stepwise therapy. Also, keep in mind that this strategy of as-needed inhaled steroid and formoterol is not currently FDA-approved and is not a labeled use of the medication, although, as I'll share in the next couple of slides, has also been embraced now by the NIH guidelines. And as you can see, the Geno 2021, for step one and two, as-needed use of low-dose ICS formoterol, with reliever also as-needed low-dose ICS formoterol, and then step three, low-dose maintenance, step four, medium-dose maintenance ICS formoterol, and of course, additional advanced therapies for step five. In this alternate reliever, this is similar to what was previously, except step one is to take inhaled steroid, and at any time that short-acting beta agonist is taken, then low-dose maintenance ICS, low-dose ICS LABA, and this can be any ICS LABA, doesn't have to be formoterol, if the reliever is as-needed short-acting beta agonist. And in all of this, the circle is equally important, which is to review and assess and adjust therapy, particularly with attention to confirming diagnosis, optimizing comorbidities, and ensuring good inhaler technique and adherence. This was the other update that I've mentioned. This was the focused update to the asthma guidelines from the National Asthma Education Prevention Program, which was updated late last year. They did not tackle step one therapy, but they did look at as-needed use of inhaled steroid, and they recommended that for step two, they recommended use daily low-dose ICS with as-needed short-acting beta agonist, or use ICS every time you use a short-acting beta agonist as-needed. And then step three looks very similar to Gina's step three, which is daily and as-needed combination low-dose ICS formoterol. And then, of course, there's step four, five, and six. So I'd recommend reviewing these guidance. I've listed the areas that they focused. Basically, phenol was recommended, as I mentioned, as a junk to evaluation in individuals five years or older. It can be used as part of ongoing asthma monitoring and management strategy, but they're recommended against use of exhaled nitric oxide levels in isolation to assess control or to predict exacerbations. And also, it cannot be used in a zero to four-year-old age group. For allergen mitigation, they recommended multi-component allergen mitigation in sensitized individuals who have exposure to indoor allergen. For pests, it was recommended to do integrated pest management alone or as part of multi-component intervention. And for dust mites, they recommended using impermeable covers only as part of multi-component intervention. The inhaled steroid also, as I mentioned, they touched upon as-needed use of inhaled steroid. Also recommended that if individuals who are zero to four years old with recurrent wheeze only with infections, recommend a short course of daily ICS and as-needed short-acting beta agonist at the onset of respiratory infection. Long-acting muscarinic antagonist in individuals who are 12 years or older with asthma that's uncontrolled on ICS and LAMA, they recommended adding LAMA. But they recommended against using LAMA, long-acting muscarinic antagonist, as the first add-on therapy to inhale steroid over LAMA. And this was mainly based on a single belt study, which I'll touch upon later, where it was a study in black patients where LAMA use was associated with worse outcomes. They recommended immunotherapy in mild to moderate allergic asthma, but recommended using subcutaneous and not sublingual immunotherapy. And they recommended against use of bronchial thermoplasty.
Video Summary
The video discusses recent updates in asthma management guidelines. Key updates include the introduction of as-needed inhaled corticosteroid and formoterol in step 1 and 2 of therapy, as well as the use of as-needed low-dose ICS formoterol as a reliever. Studies have shown that this strategy reduces exacerbations and steroid exposure. The NIH and GINA guidelines have also embraced this approach. The video also highlights the importance of assessing asthma control and severity separately and optimizing treatment accordingly. Other updates covered in the video include the use of phenotyping for evaluation, allergen mitigation strategies, and the addition of long-acting muscarinic antagonist and immunotherapy in certain cases. No credits are mentioned in the video.
Keywords
asthma management guidelines
inhaled corticosteroid
formoterol
asthma control
phenotyping
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