Management of Asthma in adolescents and adults: NAEPP 2020 guidelines

Expert Panel Recommendations for the 2020 Asthma Guideline Update

Pharmacotherapy: Intermittent Inhaled Corticosteroids (ICSs)

• In individuals aged 12 years or older with mild persistent asthma, the expert panel conditionally recommends either a daily low-dose ICS and an as-needed short-acting β₂-agonist (SABA) for quick-relief therapy or an as-needed ICS and a SABA used concomitantly (conditional recommendation, moderate certainty of evidence).

• In individuals aged 4 years or older with mild to moderate persistent asthma who are likely to be adherent to daily ICS treatment, the expert panel conditionally recommends against a short-term increase in the ICS dose for increased symptoms or decreased peak flow (conditional recommendation, low certainty of evidence).

• In individuals aged 4 years or older with moderate to severe persistent asthma, the expert panel recommends ICS-formoterol therapy in a single inhaler used as both daily controller and reliever therapy (strong recommendation, high certainty of evidence for those older than 12 years) compared with either a higher-dose ICS as daily controller therapy and a SABA for quick-relief therapy or same-dose ICS–long-acting β₂-agonist (LABA) therapy as daily controller therapy and a SABA for quick-relief therapy.

• In individuals aged 12 years or older with moderate to severe persistent asthma, the expert panel conditionally recommends ICS-formoterol therapy in a single inhaler used as both daily controller and reliever therapy compared with higher-dose ICS-LABA therapy as daily controller therapy and a SABA for quick-relief therapy (conditional recommendation, high certainty of evidence).

Use of Long-Acting Muscarinic Antagonists (LAMAs) as Add-on Therapy

• In individuals aged 12 years or older with uncontrolled persistent asthma, the expert panel conditionally recommends against adding a LAMA to an ICS compared with adding a LABA to an ICS (conditional recommendation against, moderate certainty of evidence).

• If a LABA is not used, in individuals aged 12 years or older with uncontrolled persistent asthma, the expert panel conditionally recommends adding a LAMA to ICS controller therapy compared with continuing the same dose of ICS alone (conditional recommendation, moderate certainty of evidence).

• In individuals aged 12 years or older with uncontrolled persistent asthma, the expert panel conditionally recommends adding a LAMA to ICS-LABA therapy compared with continuing the same dose of ICS-LABA therapy (conditional recommendation, moderate certainty of evidence).

Utility of Fractional Exhaled Nitric Oxide (FeNO) in Asthma Diagnosis and Monitoring Treatment and Disease Activity

• In individuals aged 5 years or older for whom the diagnosis of asthma is uncertain using history, clinical findings, clinical course, and spirometry, including bronchodilator responsiveness testing, or in whom spirometry cannot be performed, the expert panel conditionally recommends addition of FeNO measurement as an adjunct to the evaluation process (conditional recommendation, moderate certainty of evidence).

• In individuals aged 5 years or older with persistent allergic asthma, for whom there is uncertainty in choosing, monitoring, or adjusting anti-inflammatory therapies based on history, clinical findings, and spirometry, the expert panel conditionally recommends addition of FeNO measurement as part of an ongoing asthma monitoring and management strategy that includes frequent assessments (conditional recommendation, low certainty of evidence).

• In individuals aged 5 years or older with asthma, the expert panel recommends against the use of FeNO measurement in isolation to assess asthma control, predict future exacerbations, or assess exacerbation severity. If used, it should be as part of an ongoing monitoring and management strategy (strong recommendation against, low certainty of evidence).

Allergen Reduction Strategies in Management of Asthma

• In individuals with asthma who do not have sensitization to specific indoor allergens or who do not have symptoms related to exposure to specific indoor allergens, the expert panel conditionally recommends against allergen mitigation interventions as part of routine asthma management (conditional recommendation against, low certainty of evidence).

• In individuals with asthma who have symptoms related to exposure to identified indoor allergens, confirmed by history taking or allergy testing, the expert panel conditionally recommends a multicomponent allergen-specific mitigation intervention (conditional recommendation, low certainty of evidence).

• In individuals with asthma who have sensitization or symptoms related to exposure to pests (cockroaches and rodents), the expert panel conditionally recommends the use of integrated pest management alone or as part of a multicomponent allergen-specific mitigation intervention (conditional recommendation, low certainty of evidence).

• In individuals with asthma who have sensitization or symptoms related to exposure to dust mites, the expert panel conditionally recommends impermeable pillow/mattress covers only as part of a multicomponent allergen mitigation intervention, not as a single-component intervention (conditional recommendation, moderate certainty of evidence).

Role of Subcutaneous and Sublingual Immunotherapy in Treatment of Allergic Asthma

• In individuals aged 5 years or older with mild to moderate allergic asthma, the expert panel conditionally recommends the use of subcutaneous immunotherapy as an adjunct treatment to standard pharmacotherapy in individuals whose asthma is controlled at the initiation, buildup, and maintenance phases of immunotherapy (conditional recommendation, moderate certainty of evidence).

• In individuals with persistent allergic asthma, the expert panel conditionally recommends against the use of sublingual immunotherapy in asthma treatment (conditional recommendation, moderate certainty of evidence).

Bronchial Thermoplasty

• In individuals aged 18 years or older with persistent asthma, the expert panel conditionally recommends against bronchial thermoplasty (conditional recommendation, low certainty of evidence).

• Individuals aged 18 years or older with persistent asthma who place a low value on harms (short-term worsening symptoms and unknown long-term adverse effects) and a high value on potential benefits (improvement in quality of life, a small reduction in exacerbations) might consider bronchial thermoplasty.

The expert panel made 19 recommendations, 2 of which involved only children aged 0 to 4 years. The following recommendations are not included in the list: (1) In children aged 0 to 4 years with recurrent wheezing, the expert panel recommends against FeNO measurement to predict future development of asthma (strong recommendation, low certainty of evidence). (2) In children aged 0 to 4 years with recurrent wheezing triggered by respiratory tract infections and no wheezing between infections, the expert panel conditionally recommends starting a short course of daily ICSs at the onset of a respiratory tract infection with an as-needed SABA for quick-relief therapy compared with only an as-needed SABA for quick-relief therapy (conditional recommendation, high certainty of evidence).