The Global Initiative for Asthma (GINA) is on a medical publication blitz to improve awareness about their 2021 recommendations for asthma management and prevention.
Their Global Strategy for Asthma Management and Prevention, as published earlier this year and reported in the limbic, included for the first time a two-track approach to asthma treatment.
GINA has also for years led the move away from SABA only treatment of even mild asthma in adults and adolescents.
Professor Helen Reddel told the limbic that the GINA 2021 Executive Summary on Asthma Management and Prevention is being simultaneously published in the American Journal of Respiratory and Critical Care Medicine, European Respiratory Journal, Respirology, Archivos de Broncopneumologia and the Journal of Allergy and Clinical Immunology in Practice.
The aim is to reach clinicians, including GPs, respiratory physicians and allergy specialists, across the world.
“It’s a good opportunity to explain the key recommendations and to explain the rationale for some of the recent changes. This is an attempt to get much wider awareness of doing the basics well for asthma management globally. For Australia, it also provides some thinking points.”
Professor Reddel, Chair of the GINA Science Committee and Research Leader at the Woolcock Institute of Medical Research, said that despite the evolution of strong evidence against SABA-only treatment, the issue had been contentious.
“This recommendation is based on evidence. The evidence is mounting about risks of overuse of SABA and the long term risk of OCS, even occasional courses, so anything that reduces those risks needs to be thought about seriously.”
She said GINA’s approach to mild asthma was to think about asthma management as a whole, not just one treatment step in isolation, which is the conventional way of developing guidelines.
“So what happens if you start treatment just with a blue SABA puffer? After the patient has been taking that for a few months or a few years and has learned to rely on it, what is the impact then on your ability to persuade them to take regular preventive treatment, even when they have no symptoms, to reduce their risk of severe attacks?”
“That’s part of the rationale for GINA recommending as-needed-only, low dose ICS-formoterol in step 1 – for patients with asthma symptoms less than twice a month – even though there are no studies in that very mild population.”
“In addition, there is no particular reason to think of asthma being different in those people compared with patients who have symptoms more than twice a month. This treatment option is highly effective in reducing the progression to needing OCS when increased doses are taken as asthma is worsening.”
Professor Reddel said a paper published in Lancet Respiratory Medicine in February showed that in patients with mild asthma, taking more than two puffs of as-needed ICS-formoterol in a single day reduced their risk of a severe attack in the following three weeks by about three-quarters compared to treatment with just a blue SABA puffer, and to the same extent as if they had been taking regular daily ICS.
A similar effect has been seen in maintenance and reliever therapy (MART) with ICS-formoterol.
MART for children
In children 6-11 years with moderate to severe asthma, GINA has recommended MART with budesonide-formoterol as one of several treatment options at steps 3 and 4. Other ICS-formoterol formulations have not yet been studied for MART in children.
The vexed issue is that MART is only approved for that age group in a handful of countries – New Zealand, Brazil, Indonesia, Mexico, The Philippines, Switzerland and Thailand.
“So in about 120 countries, MART is approved for 12 years and up but not so many countries have it approved for children,” Professor Reddel said.
Yet it had the potential to drive a substantial reduction in the risk of severe attacks in children, with a lower dose of ICS.
The sticking point for some is that the evidence is from a single 2006 study, however the GINA recommendation is not out of step with other guidelines.
“The new US guidelines in 2020 recommended MART for children aged 4-11 years with moderate to severe asthma, after a GRADE review of the evidence, despite there being only one study. So it’s not just GINA recommending it.”
“The US guidelines went further than GINA and made it the preferred treatment for that age group of children rather than just one of several preferred options which is what is in GINA.”