COPD and asthma treatment guidelines have changed significantly. C. Wayne Weart, PharmD, provides updates and key insights for clinicians in an AudioDigest® CME lecture.
For decades, adults and children with asthma have been told to take short-acting beta-agonists (SABA) such as albuterol for rescue relief. But with 2018 guidelines from the Global Initiative for Asthma (GINA), that age-old recommendation has changed.
With the new asthma treatment guidelines, experts now recommend that if SABAs are used, they should be combined with an inhaled corticosteroid (ICS) to reduce the risk of severe exacerbations seen in SABA-only treatment. But more importantly, clinicians may want to steer clear of SABAs altogether — even as-needed ICS-formoterol.
GINA’s guidelines come in tandem with new chronic obstructive pulmonary disease (COPD) guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Combined, the two sets of criteria represent significant sea changes in respiratory medicine. Since poring over both can be time-consuming, we’ve created a recent AudioDigest® lecture that hits the high points.
In the 42-minute CME session “Updated Treatment Guidelines for Patients with Asthma and/or COPD,” instructor C. Wayne Weart, PharmD from the Medical University of South Carolina, delivers the key insights that every family practice or asthma specialist should know, from therapy selection to new findings around COVID-19. Check out our summary below, then tune in to the full lecture and other topics on the AudioDigest® website.
Unpacking the risks of SABA-only treatment
GINA’s updated guidelines come after evidence of adverse events linked to regular use of SABAs, even when they’re only administered temporarily for as little as a week. These risks include:
- Beta-receptor downregulation
- Reduced bronchoprotection and bronchodilator response
- Rebound hyperresponsiveness
- Higher allergic response
- Increased eosinophilic airway inflammation
More serious risks are associated with higher use of SABAs, with three or more canisters per year associated with trips to the emergency department. At the highest usage, around 12 or more canisters per year, a patient’s risk of death increases.
While inhaled corticosteroids can reduce these risks, their use is rare. That’s especially true among patients with mild or infrequent symptoms — which is why GINA has introduced a two-track method for asthma management that preempts concerns with poor adherence of controller ICS.
Treatment for asthma: Two tracks to consider
With GINA’s asthma treatment guidelines, clinicians can now choose one of two tracks for mild asthma management:
- Track 1 (Preferred): Take low-dose ICS-formoterol as an as-needed reliever. This off-label option gives similar symptom control and lung function, but without the risks of SABAs.
- Track 2: Continue the SABA reliever as needed but take it with an ICS dose from a separate inhaler with every SABA use. Clinicians might see how this creates adherence risks.
These tracks evolve with the severity of the condition, starting from step 1 and progressing to step 5. More advanced steps can indicate higher ICS doses as well as add-on therapies such as IL4 and IL5 inhibitors. A separate step-up system is used for children ages 6 to 11.
COVID-19 and asthma
As long as a person’s asthma is well-controlled, they are not at high risk for worse outcomes from COVID-19, according to the guidelines. Additionally, ICS should not be stopped for those who have COVID-19. Finally, when a patient receives a COVID-19 vaccine, they should not receive biologic therapies (such as monoclonal antibodies) the same day.
Treatment for COPD: What GOLD guidelines say
After a thorough review of the new asthma guidelines, Weart offers an overview of GOLD guidelines. While these guidelines don’t change COPD treatment as radically as the GINA guidelines change asthma treatment, they categorize severity by FEV1/FVC ratios to better guide care planning.
In the resulting classification, patients are divided into stages A, B, C, and D — with stage A only requiring lifestyle changes such as smoking cessation and stage D calling for a combination of LAMA plus LABA or ICS plus LABA.
If patients have overlap between asthma and COPD, remember the risks of using bronchodilators alone. As a general practice, ICS should remain a part of treatment for these patients.
Keeping up with changes in respiratory medicine
With asthma being the most common chronic noncommunicable disease and COPD in the top five causes of death in the United States, staying current in this dynamic field is critical.
These changes are big news in the respiratory and family medicine space, and it can take some time to understand their impact. Jumpstart your research with Weart’s audio lecture, which can be accessed anywhere from any device for an easy introduction to these important recommendations.
