If you’re among the 2 in 5 Americans with asthma who use an inhaler with a daily controller medication or the nearly 1 in 4 who regularly use an inhaled “rescue medicine” for asthma flare-ups, updated guidelines from the National Institutes of Health (NIH) could mean it’s time to talk with your doctor about upgrading your asthma action plan. (Those inhaler statistics come from a report published in December 2017 in The Journal of Asthma.)
The new guidelines from the NIH’s National Asthma Education and Prevention Program (NAEPP) and the National Heart, Lung, and Blood Institute (NHLBI) were published in December 2020 in The Journal of Allergy and Clinical Immunology and on the NHLBI website. This is the first update since 2007 and covers six areas of asthma management, with the biggest impacts for kids, teens, and adults who use inhalers.
“This update is important for all healthcare practitioners who treat asthma — family medicine clinicians, pediatricians, internal medicine specialists, allergy/immunology specialists, and pulmonologists,” says Giselle S. Mosnaim, MD, who helped develop the new guidelines as the representative from the American Academy of Allergy, Asthma, and Immunology (AAAAI) on the NAEPP coordinating committee. “I think it will improve the way asthma is managed and help people with asthma and their doctors make decisions together.”
Here, four asthma experts weigh in on questions you may have about how the new guidelines could affect your asthma care.
1. I Use a Daily Inhaler for Asthma Control. Which Recommendations Apply to Me?
The new guidelines recommend that adults and teens with moderate to severe persistent asthma switch to a one-inhaler treatment strategy called SMART (single maintenance and reliever therapy). This recommendation also applies to some children ages 5 to 11, so parents of kids in this range should talk with their child’s doctor about whether it’s best to switch to SMART. (People with these types of asthma who have well-controlled disease may not need to switch therapy immediately. See below.)
“Currently, most asthma action plans for moderate to severe persistent asthma include two inhalers: a daily controller medication, plus a second inhaler with a rescue medication for flare-ups,” says Dr. Mosnaim, incoming president of the AAAAI and an allergist and immunologist with the NorthShore University HealthSystem in Chicago. “The new guidelines recommend one inhaler with a specific combination of medications for both. This streamlines daily asthma care. You don’t have to keep track of two different inhalers. Research shows it has real benefits for asthma control.”
2. How Does SMART Work?
The inhaled asthma drug used in SMART therapy is a corticosteroid plus formoterol. This combination is already widely used as a daily controller drug, as the medications budesonide plus formoterol (Symbicort) and mometasone plus formoterol (Dulera). What’s new is that the federal guidelines endorse their use as a rescue medicine, too.
“The corticosteroid reduces inflammation in your airways, which is important for keeping asthma under control and helps during a flare,” explains Michael E. Wechsler, MD, a pulmonologist and director of the Cohen Family Asthma Institute at National Jewish Health in Denver. “The formoterol is a long-acting beta-agonist that assists in keeping airways open for 6 to 14 hours. Formoterol starts acting within minutes. That means it can also provide quick relief during a flare-up.”
Dr. Weschler warns that other combination inhalers with a corticosteroid and other long-acting bronchodilators don’t work that fast and could make an asthma flare worse. They cannot be used as a substitute for SMART therapy.
3. What’s the Evidence That SMART Is Better Than Separate Inhalers?
SMART has been used around the world for more than a decade and is increasingly used in the United States, too, says Weschler.
In three studies cited in the new guidelines, SMART reduced the risk for worsening asthma — measured by rates of hospital and emergency room care, doses of inhaled and oral steroids required, or lung function status — by 37 to 40 percent compared with the conventional treatment of a corticosteroid inhaler for daily control plus a rescue inhaler with a short-acting beta-agonist drug.
“When asthma flares up and becomes exacerbated, people may end up using higher doses of their inhaled corticosteroid or need corticosteroid pills,” explains Mosnaim. These doses reduce inflammation but over time boost risk for serious side effects, particularly stunted growth in children and osteoporosis, glaucoma, cataracts, and high blood pressure in adults. Adults and children on SMART needed less corticosteroid, which could reduce risk for these side effects.
The report notes that in children ages 4 to 11, there may be a lower risk of stunted growth with SMART compared with conventional treatment using a higher daily dose of an inhaled corticosteroid.
4. Who Specifically Should Make the Switch to SMART?
Wondering if you’re in the group with a SMART recommendation? Moderate persistent asthma means that, without treatment, you have daily symptoms that interfere with activities (like wheezing, shortness of breath, chest tightness, or chronic coughing); you have symptoms that wake you up more than once a week at night; or your lung function tests are abnormal, according to the University of Michigan and the AAAAI.
Severe asthma means that, without treatment, you have symptoms throughout the day, it severely limits your daily activities, it happens frequently at night, or your lung function tests are abnormal.
Your asthma is uncontrolled if you’re still having symptoms despite using your medications.
For adults, teens, and some kids (remember to check with your child’s doctor for kids between 5 and 11) with moderate to severe persistent asthma that’s not well controlled, the switch to SMART is recommended. The recommendation applies to those who now use low- or moderate-dose corticosteroids as part of their asthma treatment.
The conventional treatment for managing moderate to severe persistent asthma has been a daily controller medication that could be an inhaled corticosteroid — such as mometasone (Asmanex), ciclesonide (Alvesco), fluticasone (Flovent), budesonide (Pulmicort), beclomethasone HFA (Qvar), and others — or a combination corticosteroid plus long-acting beta-agonist, such as fluticasone and salmeterol (Advair Diskus, Advair HFA), fluticasone and vilanterol (Breo Ellipta), Symbicort, or Dulera, according to the AAAAI. Conventional therapy also includes a second inhaler with a short-acting beta-agonist (SABA) as a rescue medication, such as albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA), or pirbuterol (Maxair Autohaler). If you have moderate to severe persistent asthma, you’re following one of these treatments, and your asthma is well controlled, you may not have to switch to SMART. Check with your doctor.
SMART involves a medium dose of inhaled corticosteroid plus formoterol. SMART is not recommended for people who already take high-dose inhaled corticosteroids, who may benefit from other asthma medications, says Payel Gupta, MD, a national volunteer medical spokesperson for the American Lung Association and an allergist associated with Mount Sinai in New York City.
5. The SMART Recommendation Applies to Me, But My Asthma Is Well Controlled With the Inhalers I Use Now. Do I Need to Switch?
You don’t have to switch to SMART if your asthma is well managed with the inhalers you have right now. But if you like the idea of one inhaler instead of two, talk to your doctor, Mosnaim suggests. Even though SMART is preferred, the guidelines say there’s no need to switch if asthma is under control.
“Not everyone is a good fit for it,” says Mohammad Younus, MD, medical director of Hackensack Meridian Health’s Center for Allergy in New Jersey. “If you’re on separate inhaled corticosteroid and short-acting beta-agonist inhalers and are well controlled, you don’t have to change.”
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6. I Think the New Guideline Applies to Me. Do I Need to Switch Treatment Right Away?
If your asthma’s not well controlled, it’s always a good idea to see your doctor as soon as possible. At that visit, you could discuss this new therapy option rather than ramping up to a higher dose of corticosteroids, Mosnaim says.
If you’re in good control, there’s no need to switch unless you want to. In that case, discuss it with your doctor at your next regular appointment.
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7. Will My Health Insurance Cover SMART Therapy?
If your doctor recommends SMART, it’s a good idea to check with your health plan about insurance coverage.
“I’m finding with my patients that the inhalers for SMART therapy aren’t covered by their insurance with enough doses for daily use and for use as a rescue medication for one month,” Mosnaim says. “That could make SMART very expensive. We hope patients, patient advocates, and doctors will talk with health insurance companies about this need.”
You may be able to get coverage by working with your doctor to get a prior use authorization to show your health insurer, says Dr. Gupta.
8. Do Any of the New Guidelines Apply to Young Children?
For children up to age 4 who wheeze only when they have a cold or other upper respiratory tract infection (regardless of whether they’ve been diagnosed with asthma or not), one of the new recommendations says these kids should be prescribed a short-acting beta-agonist rescue medication plus a few days of an inhaled corticosteroid. “This can prevent breathing problems in young children from becoming so severe that they need an oral corticosteroid or need to be hospitalized,” Dr. Younus says.
This recommendation for kids 4 and younger applies to kids who’ve had three or more wheezing episodes during respiratory tract infections in their lifetime or two in the past year.
While the therapy has benefits, it could also stunt growth, the guideline notes. But the research isn’t conclusive: One study cited by the report found a 5 percent lower gain in height and weight for young children on this therapy, but other research found no effect on those measures of growth.
People with mild persistent asthma who are 12 or older can continue using a low-dose inhaled corticosteroid for controlling their asthma and a rescue medication as needed. You have mild persistent asthma if symptoms occur on fewer than two days per week and do not interfere with everyday activities, nighttime symptoms occur two or fewer days per month, or lung function tests yield normal results when you’re not having a flare. If you have this type of asthma, you’re not in the group that is recommended to switch to SMART.
But it’s worth noting that now this group also has the option of using those two medications only at times when symptoms begin to flare up, Mosnaim says.
The guidelines say this “use as needed” strategy could be a good treatment option for people with mild persistent asthma who currently use no medication. (It’s not recommended in kids age 11 and younger because it hasn’t been well studied.)
But a daily corticosteroid for control (plus a rescue inhaler as needed) may be a better option for maintaining lung health in mild persistent asthma if you tend to not notice asthma symptoms until they’re really bothering you or if you’re extremely aware of breathing changes and might overdo rescue treatments, the guidelines say.
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9. Are There Any New Treatment Guidelines for Severe Asthma?
For teens and adults, ages 12 and older, if you have moderate to severe asthma that’s not controlled with an inhaled corticosteroid alone, your doctor should consider adding a long-acting beta-agonist (LABA). If this doesn’t help, or if you can’t use a LABA for other reasons, your doctor may consider adding another type of long-acting bronchodilator to your inhaled corticosteroid: a long-acting muscarinic antagonist (LAMA). “The improvement we see with patients on a LAMA are not that significant, but the drugs do help relieve some of their symptoms,” Younus says.
LAMAs open the airways just as LABAs do, but they work on a different cell receptor to do this, the muscarinic receptor, Gupta explains (which is why they may be a good alternative for people who don’t do well with LABAs).
The guidelines note that LAMAs shouldn’t be used by people who have glaucoma or are at risk for glaucoma. And one study suggests that LAMAs may not be a good choice for Black patients with asthma, due to a higher risk for hospitalization due to asthma.
LAMAs have been used for chronic obstructive pulmonary disease for a while but were only approved in 2015 for asthma, adds Weschler. “They aren’t a new treatment, but including them is important because this will be a go-to asthma treatment guideline for many doctors,” he says.
LAMAs are inhaled drugs. They include umeclidinium (Incruse), glycopyrrolate (Seebri), tiotropium (Spiriva), and aclidinium (Tudorza).
10. My Asthma Is Triggered by Allergies. How Could the New Guidelines Help Me?
The guidelines recommend taking steps to reduce your exposure to triggers like pollen, pet dander, dust mites, mold, cockroaches, rodents, or others if an allergy provokes your asthma symptoms.
Immunotherapy (allergy shots) can also help. Typically your allergist will do a skin test to pinpoint allergy triggers. Based on that, your doctor will determine the appropriate allergy shots, explains Younus. “It’s been around for years, and research shows it's very effective.”
The process is lengthy, including weekly in-office shots for six to seven months, followed by monthly shots for four to five years. But it makes a difference. “I see big improvements in allergic asthma in a year,” he says. “Children can play with the family pet; people can go outside in the spring comfortably.”
11. Will My Medical Visits for Asthma Change Because of the Guidelines?
Some doctors may use a breath test called fractional exhaled nitric oxide to aid in the diagnosis and management of asthma, Mosnaim says.
The test looks for airway inflammation by measuring its by-product, nitric oxide. It could be used along with information about your symptoms and a lung function test called spirometry to help your doctor tell if your asthma treatment plan is working. It may also help detect asthma when other signs aren’t clear.
“If we think there’s inflammation, the person can start asthma medication and we’ll retest to see if it makes a difference,” Younus says. “It’s a good tool for asthma management.”
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