An update to the Global Initiative for Asthma 2017 Asthma report puts new emphasis on the importance of uncontrolled asthma symptoms as a risk factor for exacerbations.
The 2018 report also warns that having any of a list of specified risk factors increases the patient’s risk of exacerbations, even if they have few symptoms.
It also adds higher bronchodilator reversibility to the risk factors, which include:
- High short-acting bronchodilator (SABA) use, with increased mortality if >1x200-dose inhaler per month
- Inadequate inhaled corticosteroid (ICS) through low prescribing, poor adherence or incorrect inhaler technique
- Low FEV1 especially if <60% predicted
GINA has also identified chronic sinusitis as a risk factor for exacerbations, adding that all of the above can be assessed in primary care.
GINA states that fractional exhaled nitric oxide (FeNO) testing can be considered for guiding treatment decisions, and can significantly reduce exacerbation rates – at least in children. GINA says that FeNO can be used to support a decision to start ICS, but warns that it should not be used to withhold ICS in patients with a low initial FeNO result, and further research is needed into the optimal frequency of FeNO monitoring.
The updated guidance says SABAs are highly effective for the quick relief of symptoms as a first step for patients with very intermittent symptoms, but reminds clinicians that there is insufficient evidence for the safety of SABA-only therapy for patients with more frequent symptoms or any risk factor for exacerbation: ICS should be considered for these patients to reduce the risk of exacerbations.
For patients who need therapy stepped up from ICS and as-needed SABA, GINA recommends adding LABA to ICS in a combination inhaler as this provides additional improvement in lung function with a reduced risk of exacerbations compared with the same dose of ICS. However, this approach may lead to only a small reduction in SABA use.
GINA. Global strategy for asthma management and prevention (2018 update).