Abstract
Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma.Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients’ adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and “low dose ICS taken whenever SABA is taken”.The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and “ICS taken whenever SABA is taken” are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.
Highlights
Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation [1]
The results in terms of ongoing asthma symptom control were slightly better in the Symbicort Given as Needed in Mild Asthma (SYGMA) trials for the maintenance regimen of daily low dose budesonide compared with the as-needed regimen of budesonide-formoterol, adherence to regular inhaled corticosteroids (ICS) is considered an issue in patients with very mild asthma requiring only Step 1 treatment
The Steroids in Eosinophil Negative Asthma (SIENA) trial had a small sample and a relatively short follow up, the results provide a signal towards the consideration of phenotype-based treatment rather than blanket recommendations, i.e. for low dose ICS for all patients with mild asthma [38]
Summary
Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation [1]. Muneswarao et al Respiratory Research (2019) 20:183 burden, including hospitalisation, a greater progressive decline in lung function, impairment in quality of life (QoL) and death [9–13]. Asthma patients with exacerbations requiring an emergency department visit or hospitalisation are at increased risk for future exacerbations, independent of demographic, clinical factors, asthma severity and asthma control [14]. Asthma exacerbations have been shown to cause a significant financial burden on health systems [15]. In a US study which retrospectively analysed administrative claims data, asthma patients who experienced exacerbations had nearly twice the health care and asthma specific costs compared with patients without exacerbations [16]. Preventing the risk of future exacerbations is, an important target, in patients with mild asthma, where there may be complacence both by the patient or their health professionals
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