The Global Initiative for Asthma 2019 recommendation for mild asthma – A critique (original) (raw)
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Clinical and Translational Allergy, 2020
New recommendations from the Global Initiative for Asthma (GINA) were released in a pocket guide form on April 12, 2019. These recommendations provide very important changes to the management of asthma, especially regarding the treatment of intermittent and mild asthma. Due to safety concerns, GINA experts no longer recommend treatment with a short-acting β2 agonist alone. Henceforth, all adults and adolescents (but not yet children) with mild asthma should receive either symptom-driven or daily low-dose ICS. The main goal of this new approach is to reduce the risk of serious asthma exacerbations and asthma-related deaths in the population of patients with mild asthma. Herein, the authors present the epidemiological and clinical data regarding the risks of excessive SABA use and the benefits of regular treatment with inhaled corticosteroids. The authors deliver a critical review on the evolution of the changes in the GINA experts' standpoint and provide evidence-based background for the new approach to asthma treatment. Moreover, the authors identify gaps and unmet needs still present in the current asthma management recommendations and discuss them thoroughly.
Randomized Comparison of Strategies for Reducing Treatment in Mild Persistent Asthma
New England Journal of Medicine, 2007
Background Treatment guidelines recommend the use of inhaled corticosteroids in patients with asthma who have persistent symptoms and the "stepping down" of therapy to the minimum needed to maintain control of asthma. Whether patients with asthma that is well controlled with the use of inhaled corticosteroids twice daily can receive a stepdown treatment with once-daily montelukast (our primary hypothesis) or once-daily fluticasone propionate plus salmeterol (our secondary hypothesis) has not yet been determined. Methods We randomly assigned 500 patients with asthma that was well controlled by inhaled fluticasone (100 μg twice daily) to receive continued fluticasone (100 μg twice daily) (169 patients), montelukast (5 or 10 mg each night) (166 patients), or fluticasone (100 μg) plus salmeterol (50 μg) each night (165 patients). Treatment was administered for 16 weeks in a double-blind manner. The primary outcome was the time to treatment failure. Results Approximately 20% of patients assigned to receive continued fluticasone or switched to treatment with fluticasone plus salmeterol had treatment failure, as compared with 30.3% of subjects switched to montelukast. The hazard ratio for both comparisons was 1.6 (95% confidence interval, 1.1 to 2.6; P = 0.03). The percentage of days on which patients were free of asthma symptoms (78.7 to 85.8%) was similar across the three groups. Conclusions Patients with asthma that is well controlled with the use of twice-daily inhaled fluticasone can be switched to once-daily fluticasone plus salmeterol without increased rates of treatment failure. A switch to montelukast results in an increased rate of treatment failure and decreased asthma control; however, patients taking montelukast remained free of symptoms on 78.7% of treatment days. (ClinicalTrials.gov number, NCT00156819.
Variability of symptoms in mild persistent asthma: baseline data from the MIAMI study
Respiratory medicine, 2004
To describe the variability of the asthma phenotype in patients with mild persistent asthma enrolled in the Mild Asthma Montelukast versus Inhaled Corticosteroid (MIAMI) study. The variability of asthma rescue-free days, asthma symptoms, albuterol use, medical resource use, and exercise Limitations among patients with documented mild persistent asthma was compared between the month before study enrollment and the last 2 weeks of the run-in period. Patients eligible for randomization (n = 400), aged 15-85 years, exhibited symptoms (mean +/- SD) 3.6 +/- 1.3 days/week, beta-agonist use 3.5 +/- 1.3 days/week, and normal FEV1 (94.0 +/- 9.9% predicted) during the last 2 weeks of the run-in period. In the year before enrollment, medical intervention for asthma flares was common: 38.5% made office visits, 15.8% had oral corticosteroids, and 8.3% required emergency room or hospitalized care. In the month before enrollment, 11.8% experienced daily symptoms, and 28.3% had limitations of normal...
Impact of ‘mild’ asthma on health outcomes: findings of a systematic search of the literature
Respiratory Medicine, 2005
The present bibliographic review shows that patients considered to have mild asthma often suffer impairment in quality of life (QoL) and use considerable scheduled and unscheduled health care resources. I found that asthma investigators used no consistent classification scheme for asthma severity, and the level of agreement amongst specialists when categorizing patients with asthma was low. Asthma severity has been classified using a wide range of parameters including medication use, asthma symptoms, lung function, hospitalizations and incidence of exacerbations. Most studies showed a general association between asthma severity and health-related quality of life (HRQoL) such that patients with severe disease suffered greater impairment. However, few patients with mild asthma enjoyed unimpaired HRQoL. Indeed depression and impaired HRQoL were reported as frequently in patients with mild asthma as in those with more severe disease. Although in general severe patients used the most health care resources, even patients with mild asthma used considerable health care resources including emergency room care and hospitalizations. In summary, the term 'mild' when applied to asthma is potentially misleading given the impaired HRQoL and avoidable health care utilization prevalent amongst such patients. The application of disease severity classification in clinical asthma management has not been validated. It may now be appropriate to examine these classifications more critically in order to determine if they have clinical or research usefulness. By contrast, the strategy of treating to achieve disease control has been validated and offers the advantage of simplicity in its application.