Smart Therapy Approach for Asthma Management
The cornerstone of a smart therapy approach to asthma is the assessment of severity to initiate therapy and assessment of control to adjust therapy, incorporating both current impairment and future risk domains to guide treatment decisions. 1
Key Components of Smart Asthma Therapy
Assessment-Based Framework
- Severity Assessment: Used to initiate appropriate therapy level
- Control Assessment: Used to adjust therapy up or down 1
- Dual Domains Evaluation:
- Impairment: Frequency and intensity of symptoms, lung function, daily activity limitations
- Risk: Likelihood of exacerbations, progressive lung function decline, medication side effects 1
Stepwise Treatment Approach
- Expanded from 4 to 6 steps of care to allow more precise therapy matching 1
- Treatment intensity increases with increasing severity or decreasing control
- Before stepping up therapy, always assess:
- Medication adherence
- Inhaler technique
- Environmental control measures 1
Medication Strategy
- Inhaled Corticosteroids (ICS): Remain the most effective long-term controller across all age groups 1, 2
- Combination Therapy: ICS/formoterol as both maintenance and reliever therapy (SMART) is preferred for patients ≥5 years old at steps 3 and 4 1
- Novel Approaches:
Personalized Monitoring
- Regular assessment using multiple measures, not just symptoms 1
- Monitoring both domains: current impairment and future risk 1
- Recognition that some patients remain at high risk for exacerbations despite minimal day-to-day symptoms 1
Smart Implementation Strategies
Patient Education and Self-Management
- Teaching self-monitoring skills and asthma management 1
- Using written asthma action plans with:
- Daily treatment instructions
- Clear guidance for recognizing and handling worsening asthma 1
- Expanding educational opportunities beyond physician offices to:
- Pharmacies
- Schools
- Community centers
- Patients' homes 1
Biomarker Integration
- Fractional exhaled nitric oxide (FENO) testing may be useful for some patients, though it adds limited benefit when guidelines-based care is already optimized 1
- Systems biology approaches using various 'omics' techniques combined with careful phenotyping may identify new biomarkers 1
Technology Utilization
- Electronic medical records-based asthma disease management programs to:
- Track symptoms, bronchodilator use, and nighttime exacerbations
- Monitor pulmonary function and adherence
- Guide treatment step adjustments 1
- Technology for monitoring medication adherence and physiological variations 1
- Telemedicine for improved access to specialist care 1
Addressing Difficult-to-Control Asthma
Comprehensive Evaluation
- Confirm asthma diagnosis and exclude other airway diseases 3
- Identify and address exacerbating factors:
- Unrecognized allergens
- Occupational sensitizers
- Dietary additives
- Medications
- Gastroesophageal reflux
- Upper airway disease 3
Categorization of Severe Asthma
- Untreated severe asthma
- Difficult-to-treat severe asthma
- Treatment-resistant severe asthma 4
Advanced Therapies
- For severe allergic asthma: Consider omalizumab (anti-IgE) 2
- For treatment-resistant cases: Consider referral to asthma specialist for evaluation of additional controllers or immunosuppressive treatments 3
Common Pitfalls to Avoid
- Undertreatment: Remains common despite availability of effective therapies 5
- Misdiagnosis: Ensure proper diagnosis and exclude conditions like COPD or vocal cord dysfunction 3
- Poor Adherence: A common reason for inadequate response to therapy 3
- Overlooking Comorbidities: Conditions like GERD, obstructive sleep apnea, and allergic bronchopulmonary aspergillosis may complicate asthma management 1
- Failure to Step Down: When asthma is well-controlled for at least 3 months, treatment should be stepped down to find minimum effective dose 2
- Relying on Single Measures: Using multiple measures to assess control is essential 1
A smart therapy approach to asthma requires systematic application of guidelines-based care with regular monitoring and adjustment of treatment based on both symptom control and exacerbation risk. This approach has been shown to significantly improve asthma control, even in challenging populations such as inner-city adolescents and young adults 1.