by Adam S . Price , MD ;
CASE Cover REPORT Story 1 Robert D . Pesek , MD ; 1 , 2 A . L . Simmons , MD ; 1 Matthew C . Pertzborn , MD ; 1 Tamara T . Perry , MD ; 1 , 2
Akilah A . Jefferson , MD , MSc ; 1 , 2 Erhan Ararat , MD 1 ; Jessica Cunningham , MD ; 1 Emily G . Kocurek , MD ; 3 Joshua L . Kennedy , MD 1 , 2 , 3 *
1
Department of Pediatrics , UAMS , Little Rock , Ark ., 2 Arkansas Children ’ s Research Institute , Little Rock , Ark .,
3
Department of Internal Medicine , UAMS , Little Rock , Ark .
National Heart Lung and Blood Institute ( NHLBI ) Expert Panel Review ( EPR ) -3
2020 Focused Updates to the Asthma Management Guidelines : What Should Every Physician Know ?
Abstract
Asthma is one of the most common chronic diseases and comprises a spectrum of different phenotypes and endotypes . Assessment of asthma severity and control requires a multifaceted approach with focus on day-to-day symptom control , spirometry , and exacerbation frequency . Care for asthma has changed dramatically since the inaugural report of the National Heart Lung and Blood Institute ( NHLBI ) National Asthma Education and Prevention Program ( NAEPP ) Expert Panel in 1991 and continues to advance even since the updated guidelines in 2007 . The NAEPP Expert Panel reconvened in 2020 to answer focused questions regarding asthma management . Here we address these changes that we believe to have the most bearing to primary care , including guidelines involving inhaled corticosteroids ( ICS ), ICS-long-acting beta-agonists ( LABA ), long-acting muscarinic antagonists ( LAMA ), and indoor allergen mitigation . beta-agonists ( LABA ), long-acting muscarinic antagonists ( LAMA ), indoor allergen mitigation , immunotherapy for allergic asthmatics , utility of fractional exhaled nitric oxide ( FeNO ) for diagnosis and treatment response , and bronchial thermoplasty . 1 For the purposes of this article , we will focus on guideline changes involving ICS , ICS-LABA , LAMA , and indoor allergen mitigation , as we believe that these have the most bearing to primary care .
Asthma Diagnosis and Severity Classification
As reflected in previously established NHLBI guidelines , the diagnosis and classification of asthma severity consists of four classes : intermittent , mild persistent , moderate persistent , and severe persistent asthma , with each class correlating to step-wise therapies for age-specific demographics ( 0-4 , 5-11 , and 12 + years of
Comparative Daily Dosing for Inhaled Corticosteroids
age ) that can be tailored to the individual patient . Determining severity continues to depend on two key components , which are day-to-day “ impairment ” defined by daytime symptoms , nighttime awakenings , use of albuterol , activity limitation , lung function , and “ risk ” for future exacerbations , characterized by the number of asthma exacerbations in the past year .
Asthma Management
Inhaled Corticosteroids
In a paradigm shift , the Expert Panel revised recommendations regarding the use of inhaled corticosteroids as both an intermittent and rescue therapy rather than solely as controller therapy ( Table 1 ). Though other ICS either have been studied or are in the process of being studied , the Expert Panel primarily utilized studies of budesonide when developing these guidelines . 1 In our expert opinion , we believe that the
Introduction
Asthma is one of the most common chronic diseases and comprises a spectrum of different phenotypes and endotypes . Often diagnosed in childhood , assessment of asthma severity and disease control requires a multifaceted approach with focus on day-to-day symptom control , spirometry , and exacerbation frequency .
Medication
Beclomethasone HFA
Budesonide DPI
Child ( ≤ 5 yrs .)
Daily Dose ( mcg )
Low Medium High
Child ( 5- 11 yrs .)
Adult ( ≥ 12 yrs .)
Child ( ≤ 5 yrs .)
100 50-100 80-240 NA
200 100-200 180-540 NA
Child ( 5- 11 yrs .)
> 100- 200
> 200- 400
Adult ( ≥ 12 yrs .)
> 240- 480
> 540- 1080
Child ( ≤ 5 yrs .)
Child ( 5- 11 yrs .)
Adult ( ≥ 12 yrs .)
NA > 200 > 480
NA > 400 > 1080
Since its inaugural report in 1991 , the National Heart Lung and Blood Institute ( NHLBI ) National Asthma Education and Prevention Program ( NAEPP ) Expert Panel has periodically revised the clinical guidelines for the diagnosis and management of asthma , with the most recent updates published in December 2020 . The Expert Panel identified six specific topics warranting updated guidance including the use of as needed / rescue inhaled corticosteroids ( ICS ), maintenance and as needed ICS-long-acting
Budesonide ( nebule )
250-500 250-500 NA
Fluticasone HFA 100 100-200 44-264
> 500- 1000
> 100- 352
Fluticasone DPI NA 100-200 100-300 NA
Mometasone DPI NA 110 110-220 NA
> 500- 1000
> 200- 500
> 200- 400
> 220- 440
NA > 1000 > 1000 NA
> 264- 440
> 300- 500
Table 1 . Estimated comparative daily dosages for inhaled corticosteroids in children and adults .
> 352 > 500 > 440
NA > 400 > 500
220-440 NA > 440 > 440
164 • The Journal of the Arkansas Medical Society www . ArkMed . org