New Asthma Treatment Guidelines Outline Radical Shift in Disease Management

As many family medicine physicians and practitioners know, asthma ranks as the world’s most common chronic non-communicable disease, affecting more than 262 million people globally as of 20191. This reversible disease causes inflammation in the lungs and airways, leading to repeated episodes of wheezing, breathlessness, chest tightness, and nighttime and/or early morning coughing.

According to data from the Centers for Disease Control and Prevention (CDC), more than 25.26 million Americans, or roughly 7.8% of the U.S. population, currently live with asthma. While the environmental equation is somewhat within the control of the patient with asthma, the pharmacological aspect is the domain of family medicine practitioners, pulmonology experts, and other physicians.

One of the most recognized asthma experts today is C. Wayne Weart, PharmD, Professor Emeritus of Clinical Pharmacy, Family Medicine, and Outcome Sciences at Medical University of South Carolina. In an approximately 43-minute lecture exclusive to AudioDigest, Dr. Weart details updated asthma treatment guidelines – along with recently revisited Chronic Obstructive Pulmonary Disease (COPD) treatment guidelines – for today’s patients. In compliance with social-distancing guidelines due to the COVID-19 pandemic, AudioDigest used virtual teleconference software to record Dr. Weart’s informative talk on June 4, 2021.

“The new, updated GINA guidelines for patients with asthma are pretty radically changed from where we have been over the last 50 years,” says Weart at the outset of the lecture. “They’re pretty significantly changed from where they’ve been in the past. Providers are not aware of some of these changes.”

Treatment for Asthma Using Global Initiative for Asthma 2019 Guidelines

The Global Initiative for Asthma (GINA) guidelines are developed via a joint effort between the National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). While it’s customary for these guidelines to be updated every year, what transpired in 20191 was far from “business as usual” at GINA. In fact, a fundamental change in asthma management was directed by this governing body just a few years ago.

“In 20191, GINA gets together, and they said, ‘We have a fundamental change in asthma management.’ Short-acting bronchodilators alone are no longer recommended for management of adults and adolescents with asthma,” states Weart in his lecture. “Up until 20191, that’s the number one therapy we use for the rescue of anyone when they have an asthma attack. Those are the drugs we’ve been using for 50 years to manage patients with asthma. So, this is a major, major change.”

In his lecture, Weart goes into great detail regarding the nature of these revised asthma treatment guidelines. GINA’s shift away from short-acting β-agonist (SABA)-only bronchodilator treatment for adults and adolescents was based on evidence that SABA-only treatment increases the risk for death, hospitalizations, and severe exacerbations — and that adding an inhaled corticosteroid (ICS) significantly reduces this risk.

As Dr. Weart also indicates in his talk, around 24% of U.S. asthma patients suffer from severe asthma. Patients with apparently mild asthma, however, remain at risk for serious adverse events. In fact, 16% of patients with near-fatal episodes have a history of mild asthma, as do 15-20% of adults who died from asthma.

Updates from GINA were also made regarding asthma in children aged six to 11 years. Dr. Weart goes into great detail here in his lecture, outlining a particular five-step approach to treatment for asthma.

Serious discussion and treatment adjustment around SARS-CoV2 and its resultant infectious disease, COVID-19, were also addressed. Novel GINA guidelines were issued involving COVID-19 and patients with asthma, and the verdict was that patients with well-controlled asthma are not at high risk for bad outcomes with COVID-19.

“Have there been more asthma exacerbations during the pandemic?” asks Dr. Weart in his lecture. “No, because we’ve reduced the risk of respiratory infections. Asthma has not gotten worse during COVID-19. It’s actually gotten slightly better.”

Short-Acting, β-Agonist-Only (SABA) Treatment in Asthma Patients: Assessing Risks

Dr. Weart also addresses the regular use of SABA treatment for asthma, which does come with some inherent risks that are important to be aware of — and discuss with patients. Regular use of SABA, even for 1 or 2 weeks, is associated with adverse events such as β-receptor downregulation, decreased bronchoprotection, rebound hyperresponsiveness, decreased bronchodilator response, increased allergic response, and increased eosinophilic airway inflammation.

Choosing the Appropriate Therapy for Patients with Stable COPD

While GINA guidelines inform the prevailing medical treatment for asthma, chronic obstructive pulmonary disease (COPD) treatment guidelines are determined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), with strong contributions from National Heart, Lung, and Blood Institute (NHLBI) World Health. These guidelines were updated in 2021, though as Dr. Weart notes in his talk, “they are not as radically changed as the asthma guidelines.”

While the updated asthma treatment guidelines from GINA firmly state that successful asthma treatment should not be confined solely to bronchodilators, updated COPD guidelines direct clinicians to begin treatment with LABA and/or LAMA without an ICS. For patients with stable COPD, a combination of SABA and SAMA bronchodilators is superior to either alone for improving symptoms and forced expiratory volume (FEV).

As Dr. Weart notes in his lecture, however, patients with features of both asthma and COPD are more likely to die or be hospitalized if treated with LABA alone, as opposed to ICS-LABA.

“They are not mutually exclusive,” explains Dr. Weart. “You can have both. Each includes several phenotypes and likely has different underlying mechanisms. The evidence supports safety-based differences in treatment recommendations.”

Deepen Your Knowledge and Earn Family Practice CME

When healthcare professionals seek to build their knowledge base and grow their family practice, they can find a trusted, experienced (70-plus years), and valuable partner in AudioDigest. If you found Dr. Weart’s lecture and this corresponding blog post to be informative and engaging, we encourage you to take a deeper dive into vital AudioDigest content from renowned experts and thought leaders. These Top 5 CME Lectures in Family Medicine are a great place to start.

You can also purchase an AudioDigest Gold subscription and enjoy anytime, anywhere access to hundreds of ACCME- and ANCC-accredited lectures. Listen to CME/CE/MOC-certified content like Dr. Weart’s on your schedule, whenever and wherever you choose. Each lecture also includes a detailed written summary, suggested readings, and helpful test questions.

1 Lecture was recorded referencing GINA guidelines updates and asthma statistics reported in 2019.