NIH Updates Federal Asthma Guidelines

The National Institutes of Health (NIH) today released updated guidelines for diagnosis, management and treatment of asthma. It is the first update to federal asthma guidelines since 2007. This is a “focused update” limited to six key areas.

The guidelines support shared decision making among primary care physicians, asthma specialists and patients. This focused update covers six key areas:

• Inhaled corticosteroids (steroids)
• Long acting antimuscarinic agents (LAMA)
• Reduction of exposure to indoor asthma triggers
• Immunotherapy or allergy shots
• Fractional exhaled nitrous oxygen (FeNO) tests
• Bronchial thermoplasty (BT)

NIH sought comments from asthma specialists and patients to revise the guidelines. The National Asthma Education Prevention Program (NAEPP) expert panel led the update process. The Agency for Health Research and Quality reviewed the guidelines before publication. Allergy & Asthma Network submitted comments throughout the two year process to provide input to the revisions of the guidelines.

“Since the last update, we have made substantial progress in understanding how to treat asthma in both children and adults,” says Michelle Cloutier, MD, chair of the National Heart, Lung and Blood Institute’s NAEPP Coordinating Committee. “The guidance reflects some of these new approaches.”

The guidelines were published in The Journal of Allergy and Clinical Immunology.

What are some of the key changes to the federal asthma guidelines?

Inhaled Corticosteroids

Using inhaled corticosteroids (ICS) when needed for recurrent wheezing or persistent asthma. ICS control inflammation, or swelling, in your airways. ICS is the controller medication prescribed for asthma.

The new guidelines include five more specific recommendations for ICS therapy. One is a major change: people 4 years of age or older with moderate to severe persistent asthma should be treated with a single inhaler of ICS called-formoterol. Formoterol can be used daily and as needed.

Long acting antimuscanaric agents (LAMAs)

Using long-acting antimuscarinic agents (LAMAs) with inhaled corticosteroids for long-term asthma management. A LAMA is an inhaled medicine that helps to keep airway muscles relaxed.

The new guidelines recommend that patients with uncontrolled asthma use a long-acting beta-agonist (LABA) with inhaled corticosteroids as treatment. However LAMAs can be used if a LABA cannot be used for any reason.

Reduction of exposure to indoor air triggers

Using one or more methods to reduce exposure to indoor asthma triggers. The guidelines recommend more than one targeted approach to reduce indoor allergens.

Immunotherapy (allergy shots)

Using Immunotherapy or allergy shots to make your body less sensitive to allergens (such as grass or ragweed pollen). The guidelines recommend allergy shots as an extra treatment for people with mild to moderate allergic asthma.

Fractional exhaled nitric oxide (FeNO) tests

Using fractional exhaled nitric oxide (FeNO) tests to help manage asthma or confirm a diagnosis in some patients. The test involves breathing into a tube connected to a machine that measures the amount of nitric oxide. Nitric oxide can increase when there is airway inflammation.

FeNO testing in people ages 5 and older is recommended when either the diagnosis or the approach to therapy is uncertain. The guidelines stress that FENO should not be used alone to assess asthma control. FeNo should not be used to assess the severity of an asthma attack. FENO should also not be used to predict development of asthma in children ages 4 and younger.

Bronchial thermoplasty (BT)

Using bronchial thermoplasty (BT) to treat selected adults with persistent asthma. BT is a procedure that uses heat to reduce the muscle inside the airways.

The guidelines say most adults with uncontrolled asthma should not undergo BT. The benefits are small, risks are moderate and long-term outcomes uncertain. However, some people with persistent asthma may have difficulty with other therapies. In this case, they may choose BT as part of shared decision making with their doctor.

What else is important to know about this focused update?

This 2020 update is not a full update of the national asthma guidelines. A focused updated means it is limited in scope. Guidelines for new biologic therapies, for example, are not included in these updates.

Asthma specialists often rely on additional asthma management guidelines from the Global Initiative for Asthma, also known as GINA, which is updated annually. GINA includes treatment guidelines that are not yet addressed in the NIH asthma guidelines such as biologics, asthma phenotypes and use of digital technologies.

How should someone with asthma use these updated guidelines?

The NIH’s revised guidelines are intended to improve asthma testing, management and treatment. They support informed shared decision making between patients and their doctors.

We are sharing the updates to these guidelines with patients to raise awareness about them. Your doctor may inform you of these new recommendations when considering treatment.

We encourage you to use this information to start a conversation with your doctor to better understand how the guidelines apply to your asthma care.

What are some asthma resources for patients?

NIH shared the following fact sheets to help patients better understand asthma:

• Asthma Management Guidelines and Your Care
• The Changing Role of Inhaled Corticosteroids in Asthma Management
• Long-Acting Muscarinic Antagonists (LAMAs)
• Reducing Allergens in Your Home
• Can Immunotherapy Help with the Treatment of Allergic Asthma?
• What is Fractional Exhaled Nitric Oxide (FeNO) Testing?
• Is Bronchial Thermoplasty Right for You?
• 2020 Asthma Action Plan