In 2007, The Sopranos was a hit TV show, patterned jeggings were a fashion trend, and the National Asthma Education and Prevention Program (NAEPP), sponsored by the National Institutes of Health, published the second edition of the Asthma Management Guidelines.
A lot has changed since 2007, including in the field of asthma. The NAEPP recently released the third edition of the Asthma Management Guidelines to address these changes. This update reflects recent advances in our understanding of the disease mechanisms that cause asthma, as well as current best practices for managing asthma symptoms. Therefore, the updated guidelines are an important tool in improving the ability of doctors and patients to control asthma and minimize the impact of this disease on their lives.
The number of asthmatics in the US
Asthma is a chronic lung disease that affects approximately 5 to 10% of the American population. It is characterized by symptomatic periods of wheezing, chest tightness, and shortness of breath alternating with periods of essentially normal breathing. The symptomatic episodes can be extremely debilitating and even life-threatening – approximately 3,500 people die from asthma each year, many of them children. As with many diseases, the impact of asthma is greater on minority and economically disadvantaged patients. There is no cure for asthma, so therapy focuses on preventing and treating flare-ups called exacerbations.
New asthma guidelines update treatment recommendations
The main focus of the updated guidelines is on asthma management. Most asthma therapies treat two causes of asthma symptoms: airway inflammation and airway narrowing. Airway inflammation in asthma is caused by an excessive and / or inappropriate immune response. It’s usually treated with steroids, which help control airway inflammation or swelling over time.
The narrowing of the airways is controlled by nerves in the airways. There are two main types of airway nerves, sympathetic and cholinergic. The sympathetic nerve network, especially the beta-2 nerve receptors, is the most common neural target in asthma treatment. Drugs that activate the beta-2 nerve receptors are called beta agonists. They are usually given as inhaled medication. Beta agonists are bronchodilators; They relax the muscles in the airways and allow the narrowed airways to open again. There are two basic types of beta agonists used in asthma: fast-acting, short-duration drugs (SABAs), which are used to provide immediate symptom relief; and longer-acting and (usually) delayed-on-effect drugs (LABAs) used for maintenance therapy.
Previously, asthmatics who needed daily maintenance or control therapy used separate steroid and beta-agonist inhalers to treat inflammation and narrowing of the airways. LABAs are preferred for maintenance therapy because of their longer duration of action. For patients already using a steroid and a LABA for maintenance therapy, using a SABA for breakthrough symptoms meant a second (if a steroid / LABA combination inhaler was used in maintenance therapy) or a third (if separate steroid and LABA were used) -Inhalers are used) Maintenance) Rescue inhaler. This approach is cumbersome and disruptive for patients.
The update includes instructions on how to use a new type of inhaler that combines a steroid with a LABA as a control and rescue drug. Using one inhaler for both maintenance and rescue therapy is a more effective approach than using multiple inhalers. First, it is easier to use one inhaler properly than it is to take multiple doses from multiple inhalers. Second, the use of a combination inhaler for rescue treatment results in both immediate symptom relief and an increase in steroid dose. So this approach increases the amount of both anti-constriction and anti-inflammatory drugs.
However, not all combination inhalers are suitable for this approach. To be used for both maintenance and rescue, the LABA must take effect quickly. One LABA, formoterol, sets in quickly and the guidelines describe which combination therapy is effective as both control and rescue therapy and how it can be incorporated into asthma management.
Recent evidence has shown that the cholinergic nerves are also important in regulating airway size in asthma. The updated guidelines incorporate these results and include recommendations for the use of long-acting anti-cholinergic therapies (LAMAs) such as tiotropium (Spiriva HandiHaler) or umeclidinium (Incruse Ellipta) to treat asthma.
New treatment approach targets specific inflammatory cells
The most recent studies of asthma have focused on identifying subsets of asthma patients based on different patterns of inflammation. These studies have led to the development of new therapies that specifically target certain types of inflammatory cells and their products. These therapies are very specific and do not work for all asthmatics. And they can sometimes cause serious, even life-threatening, allergic reactions. The updated guidelines provide general guidance on when to incorporate this new approach into a patient’s asthma management strategy. However, as this area is new, this edition of the Guidelines does not provide specific recommendations for these drugs.
The new guidelines also deal with the safe use of the leukotriene inhibitors zileuton (Zyflo) and montelukast (Singulair). These are effective therapies for asthma, but they can sometimes cause serious side effects. Montelukast, in particular, has been linked to depression. The FDA recently added a warning about this issue to this drug. The guidelines describe how it can be used safely.
Nitric oxide measurements can be used to diagnose asthma
The update also includes guidance on how to use new techniques to diagnose asthma. The activity of the cells that cause inflammation in the airways of people with asthma results in a by-product called nitric oxide, which is exhaled when the person breathes. Reliable measurements of exhaled nitric oxide are widely used, and the new asthma guidelines explain how these measurements can be included in the diagnosis of asthma.