The issue also includes an editorial that explains how the guideline update differs from recommendations published by other groups. Bronchial thermoplasty. Although this therapy has been approved for severe persistent asthma, the risks and uncertain long-term outcomes outweigh the small benefits in asthma control. The expert panel conditionally recommends against bronchial thermoplasty in individuals 18 and older with persistent asthma; however, those with persistent asthma who place a low value on harms and a high value on potential benefits may consider the therapy.
Fractional exhaled nitric oxide. Although fractional exhaled nitric oxide testing may be useful if an asthma diagnosis is uncertain, elevated levels may also indicate conditions such as allergic rhinitis, atopy, smoking and chronic lung conditions. Tracking fractional exhaled nitric oxide levels does not improve outcomes or quality of life, and should not be used to assess asthma control or predict future asthma exacerbations.
Subcutaneous immunotherapy should be considered if skin testing or in vitro antigen-specific immunoglobulin E testing suggests that allergen exposure worsens asthma control. Subcutaneous immunotherapy is not recommended for patients with severe asthma because of increased risk of anaphylaxis. Inhaled corticosteroids.
In children up to age 4 years who experience wheezing with respiratory infections but not between infections , a seven- to day course of daily ICS at the onset of a respiratory infection reduces exacerbations and systemic corticosteroid use.
In children age 4 years and older with moderate to severe persistent asthma, a single inhaler can be used as rescue therapy.
In single maintenance and reliever therapy, ICS and formoterol can be used in combination as daily controller therapy and as a rescue inhaler for up to eight puffs daily in children ages 4 to 11 years or 12 puffs daily in patients older than 12 years.
In patients age 12 years and older with mild persistent asthma, use of both ICS and a short-acting beta agonist as rescue therapy is equivalent to daily ICS controller therapy with SABA rescue therapy.
However, the benefit of rescue ICS therapy is uncertain in children younger than 12 years. Long-acting muscarinic antagonists. In patients with uncontrolled asthma despite daily ICS therapy, adding an inhaled long-acting beta-agonist is recommended instead of adding a LAMA, as adding a LAMA has been associated with increased hospitalizations. In addition, LAMA medications should be avoided in patients at risk of urinary retention and glaucoma.
In the editorial, Elward said the guideline update differed from the Global Initiative for Asthma recommendations in two areas: the number of issues addressed and the nature of the evidence review. The Global Initiative guidelines, Elward said, pertain to a broad range of asthma topics, whereas the focused updates targeted areas for which there was both strong interest and sufficient evidence to influence patient care.
The focused updates also used systematic reviews from the Agency for Healthcare Research and Quality and the Grading of Recommendations Assessment, Development and Evaluation methodology to assess study design and evidence relevance, and paid attention to asthma management from the perspective of primary care. Elward acknowledged some limits to the focused updates, such as the decision to center immunotherapy recommendations only as they applied to asthma and not other elements of allergy care, and to not address issues such as health care payment and insurance coverage.
He encouraged family physicians to email the expert panel to provide feedback on the recommendations and other areas where clinical questions remain. Read More. It should be noted that at this time, these guidelines have not been reviewed by the AAFP. Updates by Topic The guideline update included nearly 20 recommendations focused on six priority topics. Studies are inconclusive as to whether pet removal improves pet-related allergies. Story Highlights. Sublingual immunotherapy is not approved for asthma.
Patients with asthma should not administer immunotherapy at home. Additional Comments In the editorial, Elward said the guideline update differed from the Global Initiative for Asthma recommendations in two areas: the number of issues addressed and the nature of the evidence review.
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