Michelle Cloutier, MD, on the Focused Updates to Asthma Management Guidelines

In this podcast, Michelle M. Cloutier, MD, talks about the report from The National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) on the 2020 focused updates to asthma management guidelines, including 6 prespecified topics and 19 recommendations in the 6 topic areas. She also presented on this topic at the annual American Thoracic Society 2021 annual meeting. 

Additional Resources:

• Cloutier MM, Teach SJ, Lamanske RF Jr, Blake KV. The 2020 focused updates to the NIH asthma management guidelines: key points for pediatricians. Pediatrics. 2021;147(6):e2021050286. https://doi.org/10.1542/peds.2021-050286
• Cloutier MM, Baptist AP, Blake KV, et al; for the National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program Coordinating Committee. 2020 focused updates to the asthma management guidelines: a report from the national asthma education and prevention program coordinating committee expert panel working group. J Allergy Clin Immunol. 2020;146(6):1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003
   

Michelle M. Cloutier, MD, is a professor emerita of pediatrics and medicine at the University of Connecticut  School of Medicine in Farmington, Connecticut. 

Published in partnership with The American Thoracic Society. 

TRANSCRIPTION:

Jessica Bard: Hello, everyone. Welcome to another installment of "Podcasts360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

The National Asthma Education and Prevention Program Coordinating Committee, NAEPPCC, is a group of representatives from the major scientific, professional, governmental, and voluntary organizations interested in asthma. The committee's primary mission is to advise the National Heart, Lung, and Blood Institute on issues concerning asthma.

Dr Michelle Cloutier is here to speak with us about her session at ATS 2021 on the "2020 Focused Updates to Asthma Management Guidelines, A report from the US NAEPPCC Expert Panel Working Group." Dr Cloutier is a professor emerita of pediatrics and medicine at the University of Connecticut School of Medicine in Farmington, Connecticut.

Thank you for joining us today, Dr Cloutier. Can you please give us an overview of your session?

Dr Michelle Cloutier: This particular session examines some new guidelines and reports that have recently been published or are available for viewing by primary care and specialists.

It examines the guidelines from the NAEPP Coordinating Committee, from the National Heart, Lung, and Blood Institute. It examines the GINA report and its recommendations. It examines the treatment of severe persistent asthma to biologic therapy.

Jessica: Let's dive a little deeper. I know there are a few, but what are the priority topic areas for updates to the guidelines? What updates have been made?

Dr Cloutier: The 2020 Focused Asthma Updates to the Asthma Guidelines addressed six pre‑specified topics and made a total of 19 recommendations in the six topic areas. I'm going to try and very briefly summarize both the topic as well as the recommendation.

The new guideline made recommendations regarding the use of fractional exhaled nitric oxide, or FeNO, in asthma diagnosis and management.

The expert panel recommended the use of FeNO in asthma diagnosis when the diagnosis is uncertain and in asthma management when management decisions are uncertain. It did not recommend FeNO to diagnose asthma in young children to determine exacerbation severity or adherence to therapy.

The second topic area is allergen mitigation strategies. Here the expert panel recommended against the routine use of allergen mitigation strategies in individuals with asthma, so recommended against routine use.

However, in individuals who have a history of exposure to specific allergens and have either symptoms upon exposure or evidence of sensitization, the expert panel recommends multi‑component allergen mitigation strategies and recommends against single component mitigation strategies.

In the area of treatment, there were multiple recommendations regarding the use of inhaled corticosteroids. First, there is a recommendation for use of a short course, meaning 7 to 10 days, of inhaled corticosteroids in children zero to four years of age who wheeze with respiratory tract infections.

The second is in individuals with mild persistent asthma. There's a recommendation for intermittent and concomitant inhaled corticosteroid and short‑acting bronchodilators for treatment.

In individuals with moderate persistent asthma, the recommendation is for SMART, or single maintenance and reliever therapy, for use daily, so once or twice a day 1 to 2 puffs as needed for a total of 12 puffs per day in adults and 8 puffs per day in children.

The specific combination therapy recommended in SMART is an inhaled corticosteroid with formoterol because formoterol can be used more than twice a day, and it has a rapid onset of action.

In the management of individuals with moderate to severe persistent asthma, the expert panel recommended triple therapy. That is therapy with an inhaled corticosteroid, a long‑acting bronchodilator, and a LAMA, long‑acting muscarinic antagonist.

There were additional recommendations for LAMA use as alternative therapy in individuals with moderate to severe persistent asthma.

The fifth topic that the expert panel commented upon or made recommendations was related to immunotherapy. The expert panel recommended for subcutaneous immunotherapy as an adjunct to pharmacotherapy in individuals five years and older and recommended against the use of sublingual immunotherapy specifically for the treatment of asthma.

The final topic that the expert panel addressed was the use of bronchial thermoplasty, which is a bronchoscopic maneuver that decreases the size of airway smooth muscle and, therefore, increases the caliber of the airways.

The expert panel recommended against the routine use of bronchial thermoplasty except in individuals who strongly want the potential short‑term benefits and are not concerned about the long‑term benefits. Those are the six topics, and that is a summary of the 19 recommendations.

Jessica: That was a lot of information. You did a great job summarizing that. Thank you. How will these updates impact clinical practice in the management of asthma?

Dr Cloutier: Here in the US, the biggest change is the recommendation related to SMART therapy. This represents a significant paradigm shift for us. It is not going to be an easy shift for us to make. It's not going to be easy for us for two reasons.

The first is that the insurance companies allow or will pay for one inhaler per month. SMART therapy, by its design of saying you take one to two puffs one to two times per day and as needed, this approach to therapy will dictate the need for more than one inhaler per month. Insurance companies will need to begin to cover prescriptions for more than one inhaler per month.

The second one is one that currently SMART therapy is not included in the package insert for the major ICS‑formoterol combination that's currently available. Our understanding is that they are not going to seek FDA approval for this.

It may well be that we're going to need to look to other pharmaceutical companies to make these drugs or some workarounds to them.

Clearly, however, the literature supports the use of SMART. The expert panel made this a strong recommendation, with high certainty of evidence for ages 12 and up and moderate certainty of evidence for ages 4 to 12. The data clearly support the use of SMART and its safety.

Jessica: Were there any other topics that were suggested for updating but perhaps lacked sufficient new information to warrant an update? Can you name a few and talk about what could be next for research in asthma management guidelines?

Dr Cloutier: As you can imagine, there were a number of topics that had been suggested. These topics were discussed and decided upon back in 2014 and 2015. At the time, one of the major areas that was felt to be emerging but not ready for updating were the biologics.

At the time that the topics were being chosen, there was only one biologic on the market. Now there are many, many biologics on the market, so this topic was excluded.

The other thing that should be noted about the 2020 Focused Asthma update is that the draft report was sent out for dissemination across the country to the public, to nonprofits, to professional societies. They all commented upon them. In fact, we had more than 500 draft recommendations which were subsequently incorporated into the final document.

What's important about that is that they all mentioned all these other topics that had been discussed back in 2014, '15 but decided that there wasn't enough evidence to include in an update. Clearly, many of these areas are ripe for updating. For example, we need to go back and relook at asthma severity and how we define asthma severity.

All of us having slightly different versions, all, I mean other reports and guidelines out there have different definitions, it makes it very difficult to come to a consensus because we're defining things differently. We need to relook at that.

We also need to relook at what is a low‑dose inhaled corticosteroid, a medium dose, a high‑dose inhaled corticosteroid. We need to come to some decisions about that.

One of the things that the 2020 Focused Asthma Updates does is it talks a lot about shared decision making, about sitting down with patients and saying, "Look, here are some choices for therapy."

We need to better understand what's important for patients. We need much more work in this area. What do they prefer? What are their goals of therapy? We have our goals, but they're not necessarily the same as patient goals.

The final thing is we need to get away from one‑size‑fits‑all. Currently, we have a step diagram for individuals 12 years and up, which is the therapy for those individuals, but in fact, asthma's not a single disease. It is a syndrome. It has many different endotypes and phenotypes. We need to begin to sort these out and begin to look at therapy specifically for them.

For researchers who are doing clinical trials, the expert panel strongly urged them to better define their populations and to then bin those individual so that we could look at therapy both across studies by clear definitions and similar outcomes and also by different endotypes and phenotypes.

Jessica: This podcast is packed full of information. It's great. What's the overall take‑home message for our audience today, would you say?

Dr Cloutier: Asthma is evolving. We as clinicians need to adapt and adjust to this new information. We need to embrace the changes. We need to be better partners with our patients in managing asthma.

Jessica: Thank you for joining us today, Dr Cloutier. We really appreciate your time.

Dr Cloutier: Thank you.