Asthma in 2020: the 3 biggest developments according to ATS


By Michael Woodhead

17 Aug 2020

A/Prof Sunita Sharma

Three of the biggest developments in asthma in 2020 have involved the areas of prevention, treatment of mild disease, and new guidelines for management of severe asthma, according to a keynote presentation at  ATS 2020 virtual meeting.

Hope that asthma might be prevented by antenatal vitamin D were dashed by the negative outcomes seen in children followed up to six years of age, said Associate Professor Sunita Sharma of the Division of Pulmonary Sciences and Critical Care at University of Colorado.

Published in the NEJM in February this year, the long term results from the Vitamin D Antenatal Asthma Reduction Trial (VDAART) showed no difference in rates of asthma or recurrent wheeze in offspring of women who took vitamin D supplements during pregnancy compared to a placebo group.

The findings thus failed to confirm a hypothesis based on observational studies showing that asthma rates were increased in children of mothers with low vitamin D levels, said A/Prof Sharma.

However she said there were more positive developments in the treatment of mild asthma following the publication of the NOVEL START trial of budesonide-formoterol with as needed therapy for adults with mild asthma and intermittent symptoms.

The study led by Professor Richard Beasley of New Zealand, and including patients from Australian asthma treatment centres, showed that the risk of severe asthma exacerbations was lowered in patients who used budesonide-formoterol as needed, compared to those who used salbutamol for symptom relief or budesonide maintenance treatment.

But Associate Professor Sharma noted that maintenance therapy with budesonide was superior for asthma control symptoms.

“Which suggests that for patients for whom asthma symptoms rather than exacerbations are the most bothersome, maintenance therapy with budesonide has value,” she said

“This study offers an approach for the treatment of patients with mild asthma particularly those who experience exacerbations but have few asthma symptoms,” she concluded

Associate Professor Sharma noted also that the budesonide-formoterol treatment approach for intermittent asthma symptoms had been adopted as initial steps (1-2) in GINA guidelines, but only recommended as steps 3-5 with concurrent maintenance therapy in the National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma (EPR-4).

For the treatment of severe asthma, 2020 has seen the adoption of updated recommendations from the European Respiratory Society (ERS) and ATS Task Force, that focus on use of anti-IL5 biologics in severe eosinophilic asthma and provide biomarker cutoffs to guide the use of therapies.

Associate Professor Sharma said the new guidelines were notable for their strong recommendation for addition of tiotropium in patients with uncontrolled disease,  and a trial of macrolides to decrease exacerbations in patients with poorly controlled severe asthma.

The guidelines also recommend addition of dupilumab in adults with severe eosinophilic asthma and those with corticosteroid-dependent disease, independent of eosinophils.

“However, although this document is the first to set forth recommendations for the use of biologics in the treatment of severe eosinophilic disease, additional head-to-head trials of biologic agents are still needed to further define treatment recommendations,” she concluded.

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