Ted Segarra, MD & Nicole Anthony, MD
The New 2020 GINA Asthma treatment guidelines[1] are out! Our focus will be on Adults & Adolescents 12+ years. The biggest change to our practice in the ED is that we will no longer be sending these patients home with short-acting beta-agonist (SABA)-only PRN management, no matter the severity (or lack thereof) of the patient’s symptoms, i.e. no more albuterol MDIs for PRN use.
Instead, we will be prescribing patients an inhaled corticosteroid (ICS)-formoterol formulation EVEN FOR PRN MANAGEMENT IN MILD ASTHMA. Please read on for further details and references.
Kings County Tip: We have mometasone/formoterol and mometasone alone on formulary in the outpatient pharmacy.
There is no change in the ACUTE treatment of asthma exacerbation in the ED. In review, the treatment will continue to be albuterol/ipratropium + systemic corticosteroids (in all but the mildest of exacerbations).
THE CHANGES
1. The severity of asthma is now determined by the number of medications required to attain adequate symptom control.
– Mild asthma: Controlled on step 1 or step 2 medications.
Assessment
This can be assessed after several months on ICS controller medication
– Moderate asthma: Controlled on step 3 medications.
– Severe asthma: Controlled on step 4 or step 5 medications.
2. Initial asthma medications are now determined by the frequency of symptoms[1].
ο Daytime symptoms:
Monthly, Weekly, Daily
• Monthly [step 1]
• Weekly [step 2,3]
• Daily [step 3,4,5]
ο Nighttime symptoms:
• Weekly [step 3,4,5]
3. SABA-only (i.e. albuterol) treatment is no longer recommended for children 12+ and adults. Instead, ALL OF THESE PATIENTS should be on ICS-containing meds, both as BID daily controllers AND as PRN medications. (Children 6-11 years can continue with SABAs ONLY AS reliever medications PRN, but should also start ICS containing medications in conjunction.)
ο Increased risk of death with SABA-ONLY treatments[2] • Decreased Emergency Department visits[3]
Head-to-head comparison of ICS vs SABA
ο In comparison, ICS-containing medication use leads to:
• Decreased mortality[4, 5]
• Decreased hospitalization[3]
• Decreased severe exacerbations[3]
• Decreased symptoms
• Improved lung function[6, 7]
4. For most adults and children, treatment can begin at Step 2 (daily ICS [low dose] + ICS/LABA [low dose] PRN). ο ICS/LABA (prn or as BID controllers) = *on Kings County Formulary
Options and Dosages
ο Daily ICS =
• Budesonide 180 mcg BID (Pulmicort)
• Fluticasone 88 mcg BID (Flovent)
• Mometasone 100 mcg BID (Asmanex)*
• Budesonide 180 mcg/formoterol 4.5 mcg (Symbicort)
• Fluticasone 88mcg/salmeterol 50 mcg (Advair)
• Mometasone 200mcg/ formoterol 5 mcg (Dulera)*IN SUMMARY
FIGURE 1. Original figure of step-wise approach to asthma management for children age 12+ and adults based on GINA 2020 guidelines.[1]
Can you mix and match ICS-LABAs for PRN use and controller use?
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References
1 2020 Gina Full Report for Asthma Management and Prevention.
2 Patel, M., Pilcher, J., Reddel, H., Pritchard, A., Corin, A., Helm, C., Tofield, C., Shaw, D., Black, P., Weatherall, M., Beasley, R., & Beasley, R. (2013). Metrics of salbutamol use as predictors of future adverse outcomes in asthma. Clinical & Experimental Allergy, 43(10), 1144-1151.
3 Beasley, R., Holliday, M., Reddel, H., Braithwaite, I., Ebmeier, S., Hancox, R., Harrison, T., Houghton, C., Oldfield, K., Papi, A., Pavord, I., Williams, M., & Weatherall, M. (2019). Controlled Trial of Budesonide–Formoterol as Needed for Mild Asthma. The New England Journal of Medicine, 380(21), 2020-2030.
4 O’Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med. 2001;164(8 Pt 1):1392‐1397. doi:10.1164/ajrccm.164.8.2104102
5 Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the prevention of death from asthma. N Engl J Med. 2000;343(5):332‐336. doi:10.1056/NEJM200008033430504
6 O’Byrne PM, Pedersen S, Lamm CJ, Tan WC, Busse WW; START Investigators Group. Severe exacerbations and decline in lung function in asthma [published correction appears in Am J Respir Crit Care Med. 2010 Oct 1;182(7):983-4]. Am J Respir Crit Care Med. 2009;179(1):19‐24. doi:10.1164/rccm.200807-1126OC
7 Busse WW, Pedersen S, Pauwels RA, et al. The Inhaled Steroid Treatment As Regular Therapy in Early Asthma (START) study 5-year follow-up: effectiveness of early intervention with budesonide in mild persistent asthma. J Allergy Clin Immunol. 2008;121(5):1167‐1174. doi:10.1016/j.jaci.2008.02.029
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