What are the newest guidelines for managing asthma?

Newest Asthma Management Guidelines

The most current asthma guidelines (2024) from the Chinese Thoracic Society and 2019 GINA recommendations fundamentally shift away from SABA-only rescue therapy, now mandating that all asthma patients receive ICS-based treatment either as daily maintenance or as-needed ICS-formoterol, with treatment intensity determined by a stepwise approach based on control rather than pre-treatment severity. 1, 2

Core Paradigm Shifts in Modern Asthma Management

Elimination of SABA Monotherapy

• SABA alone as symptom relief is no longer recommended for any asthma patient not using regular ICS 1, 3
• For Step 1 (mildest asthma): as-needed low-dose ICS-formoterol is now the recommended approach rather than SABA monotherapy, even for patients with occasional symptoms occurring less than twice monthly 1, 2
• This change stems from evidence that SABA-only therapy fails to address underlying inflammation and increases exacerbation risk 4, 2

Assessment Framework: Control Over Severity

• Classify asthma severity based on the treatment step required to achieve control, not on pre-treatment symptoms 1
• Assess two distinct domains: current impairment (symptom frequency, lung function limitations, activity restrictions) and future risk (exacerbation likelihood, progressive lung function decline, medication adverse effects) 5
• These domains may respond differently to treatment and must be evaluated separately 5

Diagnostic Approach

Objective Testing Requirements

• Diagnosis requires episodic airflow obstruction symptoms, reversible airflow limitation, and exclusion of alternative diagnoses 5
• Spirometry is mandatory for patients ≥5 years old; never rely solely on subjective symptoms as both patients and physicians frequently underestimate disease severity 5, 6
• Bronchial provocation testing should be performed when FEV1 ≥70% predicted (excluding recent respiratory infections within 4 weeks) 1

Diagnostic Pathway for Unclear Cases

• When spirometry shows FEV1 ≥80% predicted but clinical suspicion remains high, initiate diagnostic anti-inflammatory therapy if: (1) PEF bronchodilation test shows ≥20% improvement, (2) FEV1 variability ≥12% and ≥200ml between tests, or (3) small airway dysfunction with FeNO ≥35 ppb 1
• Do not exclude asthma based on cutoff values alone when clinical symptoms suggest the diagnosis but provocation testing is unavailable or negative 1

Stepwise Treatment Algorithm

Step 1: Minimal Symptoms

• As-needed low-dose ICS-formoterol (budesonide-formoterol 160/4.5 μg) for patients with occasional daytime symptoms (<2 times/month, lasting hours), no nocturnal symptoms, no exacerbation risk, and FEV1 >80% predicted 1
• This represents a fundamental departure from previous SABA-only recommendations 2

Step 2: Mild Persistent Asthma

• As-needed low-dose ICS-formoterol significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy 1
• Alternative: daily low-dose ICS plus as-needed SABA, though the former is increasingly preferred 2

Steps 3-4: Moderate Asthma

• ICS-LABA combination therapy demonstrates synergistic anti-inflammatory effects equivalent to or better than doubling ICS dose alone 1
• ICS-LABA improves adherence and reduces high-dose ICS-related adverse effects 1
• For HDM-sensitized adolescents/adults with FEV1 >70% predicted and persistent symptoms despite low-to-medium dose ICS, add HDM sublingual immunotherapy 1

Step 5: Severe Uncontrolled Asthma

• Add triple therapy (ICS-LABA-LAMA) to improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium/high-dose ICS-LABA 1
• Add-on treatments (triple therapy, azithromycin, or immunotherapy) should be attempted before initiating phenotype-specific biologic therapy 3
• For persistent symptoms despite Step 5 treatment, add azithromycin 250-500 mg three times weekly for 26-48 weeks to reduce exacerbations 1

Step 6: Severe Asthma Requiring Biologics

• Severe asthma is defined as uncontrolled disease despite 3+ months of medium/high-dose ICS-LABA, treatment of comorbidities, and environmental trigger avoidance 1
• Type 2 inflammation (elevated blood/sputum eosinophils ≥150/μl, and/or FeNO ≥35 ppb, and/or atopy/elevated IgE) predominates in severe asthma and guides biologic selection 1
• Patients responding well to type 2-targeted biologics should prioritize decreasing/stopping maintenance OCS but never completely stop ICS-LABA 1
• Low-dose OCS (≤7.5 mg/day prednisone equivalent) may be added as a last resort in severe asthma 1

Monitoring and Adjustment Strategy

Follow-Up Schedule

• Schedule visits every 2-4 weeks after initial therapy, then every 1-3 months once response is achieved 1
• Regular training in correct inhaler technique is essential for optimal control 1
• Measure peak expiratory flow 15-30 minutes after starting treatment to assess response 7

Biomarker Monitoring

• Induced sputum eosinophil count is the gold standard for airway inflammation assessment, phenotype classification, and corticosteroid response prediction 1
• Peripheral blood eosinophil ≥150/μl identifies eosinophilic phenotype and predicts biologic response 1
• FeNO measurement aids in monitoring type 2 inflammation 1

Step-Down Considerations

• Before stepping up therapy, verify medication adherence, proper inhaler technique, and environmental control measures 5
• Patients achieving ≥1 year symptom-free with no exacerbations, normal/near-normal lung function, and no OCS requirement may be considered in "clinical remission" 1

Acute Exacerbation Management

Immediate Treatment

• Administer high-dose inhaled beta-agonists and systemic corticosteroids immediately for acute severe asthma 7
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical for preventing mortality 7
• For patients using budesonide-formoterol as maintenance and reliever therapy, take 1-2 additional inhalations during mild-to-moderate exacerbations (maximum 8 inhalations daily) 1

Special Situation: Vomiting with Exacerbation

• Administer IV hydrocortisone 200 mg every 6 hours instead of oral corticosteroids when vomiting is present 7
• Vomiting indicates either severe attack or oral medication intolerance, lowering the threshold for hospital admission 7
• Provide high-flow oxygen to maintain saturation and nebulized salbutamol 5 mg or terbutaline 10 mg driven by oxygen 7

Critical Contraindications

• Sedatives are absolutely contraindicated in asthmatic patients and can worsen respiratory depression 7
• Do not prescribe antibiotics unless bacterial infection is clearly documented 7

Admission Criteria

• Peak flow <33% predicted after initial nebulization requires immediate hospital referral 7
• Lower threshold for admission applies to afternoon/evening presentations, recent nocturnal symptoms, or previous severe attacks 7

Risk Stratification for Poor Outcomes

High-Risk Features Requiring Intensive Monitoring

• History of intubation and mechanical ventilation for asthma 1
• Hospitalization or emergency visit for exacerbation in the past year 1
• Current or recent OCS use 1
• No current ICS use 1
• SABA overuse (>1 canister salbutamol monthly) 1
• Psychiatric illness, psychosocial problems, or sedative use 1
• Poor medication adherence 1
• Confirmed food allergy history 1
• Comorbidities including pneumonia, diabetes, or arrhythmias 1

Special Populations and Phenotypes

Cough Variant Asthma

• Treatment principles identical to typical asthma; ICS-LABA is first choice and should be used for >8 weeks 1
• For poor therapeutic response with severe airway inflammation, add leukotriene receptor antagonist or short-term OCS (10-20 mg/day for 3-5 days) 1

Aspirin-Exacerbated Respiratory Disease

• Avoid aspirin and NSAIDs; desensitization therapy may be considered when high-dose ICS fails to control symptoms or aspirin is required for other conditions 1
• Anti-IgE, anti-IL-5, anti-IL-5Rα, or anti-IL-4Rα biologics benefit severe asthma with chronic rhinosinusitis and nasal polyps 1

Asthma-COPD Overlap

• Consider ACO diagnosis when asthma patients have persistent airflow limitation (post-bronchodilator FEV1/FVC <70%), noxious exposure history (≥10 pack-years smoking), emphysema on HRCT, and decreased diffusion capacity after 3-6 months standardized treatment 1

Safety Considerations

ICS Safety Profile

• Long-term ICS at recommended clinical doses is safe; however, prolonged high-dose therapy may cause osteoporosis, hypothalamic-pituitary-adrenal axis suppression, and increased pneumonia risk 1
• Monitor bone mineral density, growth in children, and screen for glaucoma/cataracts with long-term use 5

LABA Safety

• LABAs should never be used as monotherapy; always combine with ICS 5, 8
• The FDA black box warning emphasizes increased asthma-related deaths with LABA monotherapy 8

Patient Education and Self-Management

Written Asthma Action Plan

• All patients require a written asthma action plan including daily treatment instructions and recognition/management of worsening asthma 5
• Provide peak flow meter at discharge with instructions for self-monitoring 7
• Expand educational opportunities beyond physician offices to pharmacies, schools, community centers, and homes 5

Discharge Planning After Exacerbation

• All discharged patients require prednisolone for 1-3 weeks, increased ICS dose, and as-needed beta-agonists 7
• Ensure proper inhaler technique training before discharge 1