Asthma has long been associated with the use of inhalers to control symptoms. The new S2K guideline on the management of asthma, compiled by experts and published in March 2023, aims to change this. "For decades, we have known about medication that can be used to put asthma into remission. The patient can go out or travel on vacation without an inhaler. This is possible. This is a symptom-prevention approach," said the guideline coordinator Marek Lommatzsch, MD, PhD, head senior physician of the Pulmonology Department at the University Medicine Rostock, Germany, in a conversation with Medscape Medical News.
The guideline was created by the German Respiratory Society, and a further 11 professional societies from Germany and Austria were involved in the update. The authors comprehensively revised the guideline from 2017, and the evidence-based national disease management guideline (NVL) for general asthma care from 2020 was amended.
Erika von Mutius, MD, PhD, pediatrician and professor of pediatric allergology and pulmonology at the Dr. von Hauner Children's Hospital and director of the Institute of Asthma and Allergy Prevention at Helmholtz Munich, was not directly involved in the guideline. In a conversation with Medscape, she said, "This guideline is an informed statement that takes the development over recent years into account. It had been anticipated for some time now. For me, the input from pediatricians should be particularly noted."
Anti-Inflammatory Therapy
The significance of anti-inflammatory therapy was stressed in the NVL from 2020. The new guideline holds that anti-inflammatory therapy should be considered the primary therapeutic option. "We are making a U-turn: only treat the respiratory inflammation. Salbutamol should still only be given in exceptional cases as required," according to Lommatzsch.
In the guideline, asthma therapy is described using an updated step-by-step plan. Inhaled glucocorticoids (ICS) represent the most important pillar of therapy. ICS can be used as permanent therapy or as as-needed therapy in fixed combination with formoterol, which rapidly dilates the airways.
Allergen immunotherapy, also known as hyposensitization, and biologics are also effective anti-inflammatory treatments, Lommatzsch added. "We must ensure that these anti-inflammatory medicines are also used effectively. Mild to moderate forms of asthma can be treated easily by a primary care physician," he said. Basic diagnostics in the form of a blood sample are required. A somewhat more comprehensive medical history is also needed. "It takes a little more time and involves more than just taking the inhaler out of the cupboard."
The situation regarding children, however, is a little different with regard to anti-inflammatory therapy, von Mutius explained. "Childhood asthma has many forms, and confirming the diagnosis is not always straightforward, especially in infancy. If needed, salbutamol can be prescribed. However, the anti-inflammatory medication should usually also be administered."
She emphasized that the guideline has been designed in a sophisticated way that offers the option of "using medical experience to see what is suitable for this family or better for this patient. This is still always subject to medical judgment and responsibility. I find this really successful."
Diagnostics Using Biomarkers
The previous guideline concentrated on measuring lung function as a way of diagnosing asthmatic illness. Three biomarkers were brought to the fore:
Eosinophils in the blood
IgE levels
The FeNO test (proportion of nitrogen monoxide in exhaled air)
Slightly amended, the guideline now states that the FeNO test is implemented as "an integral component of specialist diagnosis."
The test measures the nitrogen monoxide content of exhaled air as an indicator of inflammation in the airways. However, this test must often be paid for by the patient. "In this respect, we want to give a nudge in the direction of the political decision-makers," emphasized Lommatzsch.
Von Mutius added that use of the FeNO test has not been established in many practices and outpatient clinics. The inflammatory marker is also subject to fluctuations. "This is an update to the guideline where we must wait to see the political response."
Which Biologic?
Despite treatment with the established therapies, the symptoms of asthma can persist in some people with severe forms of the condition. Biologics are highly effective for these patients and are preferable in the last stage of therapy to long-term therapy with oral steroids, which have numerous side effects. The current guideline provides an overview diagram to help decide which biologic is suitable for which patient.
"There are six biologics that can be used to treat severe asthma. Officially, almost any biologic can be taken into consideration for a patient, since the approvals overlap. Nevertheless, we known that certain patients benefit hugely from certain biologics. A targeted choice should therefore be made," explained Lommatzsch.
Biologics were mentioned in the 2020 NVL, but not to the great extent that they are in the latest version. "For first time, we have created an overview diagram for the individual choice of biologic. With it, we have now set a standard," said Lommatzsch.
Therapy with biologics has brought about rapid progress for adults. Von Mutius anticipates challenges in approving such therapeutics for pediatric treatment. "As is often the case, these therapies are not approved for young children. Meanwhile, dupilumab is approved for children aged 6 months and older; unfortunately, the indication for this is actually atopic dermatitis," she explains.
When using this therapy for pediatric patients, it is therefore important to explain the options to parents and to inform them of side effects. Severe forms of asthma are rare in children; they are uncommon in adults but are more prevalent than in children.
Children and Adolescents
One new chapter in the guideline describes giving medical advice to adolescents choosing a career. A table has been compiled that contains information regarding jobs and their respective allergy and asthma risk. The table is designed to be displayed in a medical practice.
Another chapter characterizes the interrelation between asthma and mental health. It differentiates between psychiatric comorbidities for which the patient requires professional help and the stress caused by the asthmatic illness itself. Many patients do not have a mental illness but do suffer under the everyday strain of having asthma, said Lommatzsch. Therefore, it is important to educate patients and their relatives on how to make a strength out of this supposed weakness — the asthmatic illness. "We have established a procedure for this and have summarized its key points in the guideline," said Lommatzsch.
Other updates to the guideline cover asthma in different contexts, such as in pregnant women. The updates address adrenal insufficiency as a side effect of the use of steroids over many years. In addition, the guideline contains a chapter on digital apps that can help with diagnostics and medical history.
Lommatzsch highlighted a new tool. "By using 15 key points summarized in a table, the guideline displays the essential differences between COPD [chronic obstructive pulmonary disease] and asthma in terms of the symptoms and the findings. It is the most modern table available in Germany that differentiates between the two diseases."
