New Approaches Asthma Toolkit

Webinar: New Approaches to Asthma Treatment, Selection, and Assessment

FDA Approves Albuterol/Budesonide Rescue Medication for Asthma Exacerbations
In January 2023, the FDA announced the approval of albuterol/budesonide to prevent and treat bronchoconstriction on an as-needed basis. The drug was approved at a dose of 180 mcg albuteral/160 mcg budesonide based on the randomized, double-blind, multicenter, parallel-group, event-driven MANDALA and DENALI phase 3 trials. Albuterol/budesonide (formerly called PT027) is a safe and tolerable first-in-class, pressurized metered-dose inhaler (pMDI) that acts to prevent the exacerbation of symptoms in moderate to severe asthma in adults aged 18 years and older.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee
This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities.

Exacerbations of asthma: a descriptive study of 425 severe exacerbations. The FACET International Study Group
Asthma is a fluctuating disease and the unpredictability of exacerbations causes major problems for patients. Despite their clinical and economic importance exacerbations have been little studied and they have rarely been a primary end point in intervention studies. A better understanding of the changes that precede a severe exacerbation might allow exacerbations to be predicted at an earlier stage so that preemptive treatment can be initiated.

A Paradigm Shift for Asthma Care (PDF link)
Use of single maintenance and reliever therapy has been recognized for years as an important part of asthma care globally. Now, a paradigm shift in asthma care is slowly emerging for patients with asthma of mild-to-moderate severity due to the recognition that a significant proportion of asthma exacerbations occur in these patients. The shift will continue as clinicians recognize the consequences of SCS overuse and carefully consider whether rescue therapy should include an ICS, rather than SABA alone.

Low-Dose Inhaled Corticosteroids and the Prevention of Death from Asthma
The efficacy of inhaled corticosteroids in reducing airway inflammation and hyperresponsiveness has led to their widespread use as initial therapy in the treatment of moderate-to-severe asthma in adults. However, prior to this study, information on whether inhaled corticosteroids prevent death from asthma has been sparse and inconclusive.

Beclomethasone versus placebo for chronic asthma
Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti-inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane-134a (HFA) propellant which is free from chlorofluorocarbon (CFC).

As-Needed Budesonide–Formoterol versus Maintenance Budesonide in Mild Asthma
Patients with mild asthma often rely on inhaled short-acting β2-agonists for symptom relief and have poor adherence to maintenance therapy. Another approach might be for patients to receive a fast-acting reliever plus an inhaled glucocorticoid component on an as-needed basis to address symptoms and exacerbation risk.

Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma
Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations. This study investigates whether one-time instruction in an approach involving as-needed inhaled glucocorticoid, added to existing therapy, could improve asthma outcomes in Black and Latinx patients with poorly controlled asthma.

Efficacy and safety of as-needed albuterol/budesonide versus albuterol in adults and children aged ≥4 years with moderate-to-severe asthma: rationale and design of the randomised, double-blind, active-controlled MANDALA study
Uncontrolled asthma is associated with substantial morbidity. While fast-acting bronchodilators provide quick relief from asthma symptoms, their use as rescue fails to address the underlying inflammation. Combining a short-acting beta2-agonist, such as albuterol (salbutamol), with an inhaled corticosteroid, such as budesonide, in a single inhaler as rescue therapy could help control both bronchoconstriction and inflammation, and reduce the risk of asthma exacerbations.

GINA Slide Set - Global Initiative for Asthma
A PowerPoint slide set summarizing GINA’s objectives, documents, and management recommendations from the 2023 update of the GINA Report, with background information about asthma and the burden of this disease.

Asthma Impairment and Risk Questionnaire (AIRQ™) Information for Health Care Providers
The AIRQ™ is a patient assessment tool intended to help identify patients 12 years of age and older whose health may be at risk because of uncontrolled asthma. 

Asthma Control Test (ACT)
In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing. This article describes the development of the Asthma Control Test (ACT), a brief, easy to administer, patient-based index of asthma control.

Asthma Therapy Assessment Questionnaire (ATAQ)
The Asthma Therapy Assessment Questionnaire (ATAQ) was developed as a disease management (DM) tool to identify individuals whose asthma management may be suboptimal. This brief, self-administered questionnaire generates a five-level measure of asthma control (0 = no control problems to 4 = four control problems). In addition, the ATAQ is used to identify possible barriers to good disease management.

Asthma Control Questionnaire (ACQ)
The authors generated a list of all symptoms used to assess control and sent it to 100 asthma clinicians who were members of guidelines committees (18 countries). They scored each symptom for its importance in evaluating asthma control. From the 91 responses, the five highest scoring symptoms were selected for the ACQ, thus providing strong evaluative and discriminative properties that can be used with confidence to measure asthma control. 

Improving primary care management of asthma: do we know what really works?
Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organization and workforce. Further analysis established the relevant factor components.

Asthma in the Primary Care Setting     
Asthma is one of the commonest respiratory diseases in the United States, affecting approximately 8% of adults. This article reviews the epidemiology, diagnosis, and treatment of asthma, with integration of recommendations from professional societies, with special attention to differential diagnosis. A framework for outpatient management of patients with asthma is presented, including indications for subspecialist referral.

Treatment strategies for asthma: reshaping the concept of asthma management
Asthma treatment is based on a stepwise and control-based approach that involves an iterative cycle of assessment, adjustment of the treatment and review of the response aimed to minimize symptom burden and risk of exacerbations. Anti-inflammatory treatment is the mainstay of asthma management. In this review we will discuss the rationale and barriers to the treatment of asthma that may result in poor outcomes.

Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations
Mild asthma includes intermittent and persistent mild asthma according to the Global Initiative for Asthma (GINA) classification, and affects between 50% and 75% of asthmatic patients. Nevertheless, mild asthma can lead to severe exacerbations, with a frequency ranging from 0.12 to 0.77 per patient-year. As mild asthma is the most frequent form of the disease, diagnosis and management require physicians’ particular attention.

Severe Asthma Phenotypes — How Should They Guide Evaluation and Treatment?
Although “precision medicine” approaches for patients with severe asthma are needed, there are many hurdles that must be overcome in daily practice. The National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) has been at the forefront of phenotype discovery in severe asthma for the past decade. SARP, along with other international groups, has described clinical severe asthma phenotypes in both adults and children that can be evaluated in the clinical setting.

Most Recent National Asthma Data (CDC)
The tables found at this link These tables feature the latest national and state statistics on the burden of asthma among children and adults. The data are from national and state surveillance systems administered by the Centers for Disease Control and Prevention (CDC). Links to sources are provided with each table to assist with finding additional information on the data and relevant tables and reports, including state and territory data.

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group
This report was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups.

Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study
This study examined the attitudes and actions of 3415 physician-recruited adults aged ≥ 16 years with asthma in eleven countries who were prescribed regular maintenance therapy with inhaled corticosteroids or inhaled corticosteroids plus long-acting β2-agonists. This study shows that patients with asthma receiving regular maintenance therapy still have high levels of inadequately controlled asthma.

A Study to Assess the Efficacy and Safety of Budesonide/Albuterol Metered-dose Inhaler (BDA MDI/PT027) in Adults and Children 4 Years of Age or Older With Asthma (MANDALA)
The MANDALA phase 3 randomized study evaluated the efficacy and safety of an albuterol-budesonide fixed dose combination inhaler as rescue therapy compared with albuterol alone in 3132 patients with moderate-to-severe uncontrolled asthma. In adolescent and adult patients, the fixed-dose combination of albuterol 180 μg and budesonide 160 μg used for symptoms on top of the routine maintenance therapy demonstrated a 27% reduction in the risk of severe asthma exacerbations in a time-to-event analysis (HR, 0.73; 95% CI, 0.61 to 0.88; pre-planned efficacy analysis) compared with as-needed albuterol 180 μg.

Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma
In this overview published in NEMJ, the investigators leading the MANDALA trial note, "As asthma symptoms worsen, patients typically rely on short-acting β2-agonist (SABA) rescue therapy, but SABAs do not address worsening inflammation, which leaves patients at risk for severe asthma exacerbations. The use of a fixed-dose combination of albuterol and budesonide, as compared with albuterol alone, as rescue medication might reduce the risk of severe asthma exacerbation."

Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study
These findings underscore the importance of improving the awareness of SCS-related adverse effects in patients with asthma and support the need for continuing development and identification of alternative treatments for treating asthma exacerbations and for patients with severe asthma to reduce exposure to SCS. They also point to the urgent need for reappraisal of when patients need specialist care and consideration of effective steroid-sparing medications.

Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study
This study characterizes short term use of oral corticosteroids in a contemporary outpatient population, and the risk of acute adverse events. It describes patients who use oral corticosteroids in the short term in an outpatient setting and then reports (absolute) incidence rates of adverse events in users and non-users. Using this method, each individual serves as his or her own control allowing for comparisons of adverse event rates during periods after exposure to corticosteroids versus rates during periods when not exposed.

Additional Resources

• CDC's National Asthma Control Program
  The CDC’s National Asthma Control Program (NACP) was created in 1999 to help the millions of people with asthma in the United States gain control over their disease.
  
  The program’s goals include reducing the number of deaths, hospitalizations, emergency department visits, school days or workdays missed, and limitations on activity due to asthma. Today, CDC funds 25 state, territorial, and municipal health departments to ensure the availability of and access to guidelines-based medical management and pharmacotherapy for all people with asthma and to address the intersection of public health and health care through funding state programs and national organizations, promoting asthma quality measures, and informing policy makers about the burden of asthma.
  
  Here you’ll find information on state and regional programs, reducing emergencies among children with asthma, and much more!

• CDC: COVID-19 and People Who Have Moderate-to-Severe Asthma
  People with moderate-to-severe or uncontrolled asthma are more likely to be hospitalized from COVID-19. Here’s everything that you and your patients with asthma need to know about COVID, including steps to take to avoid exacerbations that can lead to hospitalization. Learn more here.

• Webinar: Environmental Management of Pediatric Asthma: Guidelines for Healthcare Providers
  This online educational activity for Physicians, Registered Nurses, Respiratory Therapists, School Nurses, Community Health Workers, Social Workers, Public Health Professionals, and Health Educators supports the development of skills and knowledge required by physicians to effectively manage and improve health outcomes for children with asthma. Following this approach, interdisciplinary teams can achieve successful asthma management for children and their caregivers that builds patient and family capacity for asthma self-management, self-advocacy, and learning.

This activity provides the impetus for healthcare providers to actively collaborate with patients, parents, and caregivers to identify environmental triggers and implement evidence-based environmental interventions for asthma. Watch the video here.

•  The Allergy Asthma Network Healthcare Professionals Portal

The Allergy & Asthma Network works in partnership with the healthcare community to assist in mutual efforts to improve the quality of life and health for Americans with asthma, allergies and related conditions. You’ll find material to print for your patients and office (posters, brochures, etc.), tools for shared decision-making, as well as professional webinars, advanced certifications, special events, and much more.

 

Practical considerations for the management of asthma (National Institute of Health/Asthma) (PDF link)

1. Reliever therapies: Maximum puffs of ICS-Formoterol per day =12 puffs or 54mcg of formoterol
2. Patients advised to use 1 to 2 puffs as needed up to the maximum dose during periods of acute symptoms. Alternatively, use ICS whenever SABA is taken (Step 2)
   
3. Do not use ICS-formoterol reliever in those on other ICS-LABA maintenance regimens
   
4. IF patients are uncontrolled on maintenance ICS-LABA with SABA reliever -> consider SMART prior to increasing step therapy
5. Patients with high prevalence of daily symptoms may not be the ideal candidates for as-needed therapies

You can read the full document from the National Institute of Health/Asthma here (PDF link) 

Webinar: A New Era for Treating and Preventing Asthma Exacerbations

Patients with uncontrolled asthma are at risk for exacerbations, even if their disease is classified as mild or moderate. Recent data provide a better understanding of the role of inhaled corticosteroid (ICS) use concurrently with short-acting beta2-agonists (SABAs), and primary care clinicians are key practitioners at the forefront of this paradigm shift. This webinar addresses clinical knowledge gaps that may prove to be barriers to improving outcomes in patients with uncontrolled mild or moderate asthma.

CME credit is available from October 15, 2023, to October 14, 2024, and if you are interested in receiving credit, please follow the link above or click here for additional information.

Click here to take the post-presentation survey and earn your 1.0 credit.