Selected Podcast
New Asthma Guidelines: A Paradigm Shift in Asthma Management
The national Asthma Education and Prevention Program (NAEPP) published the first expert panel report on the diagnosis and management of asthma in 1991. A comprehensive revision was published in 1997, and an update in 2002. the EPR 3 was published in 2007. The most recent guidelines, published in 2020, represent a paradigm shift in asthma treatment.
Featured Speaker:
Learn more about Dr. Mokhallati
Nadine Mokhallati, MD
Dr. Mokhallati is a pediatric pulmonologist at Children's Mercy Kansas City where she is the Medical Director of the Pulmonary Function Laboratory. She is active in clinical care and asthma-related research and represents CM nationally with the American Thoracic Society and the American Telemedicine Association.Learn more about Dr. Mokhallati
Transcription:
New Asthma Guidelines: A Paradigm Shift in Asthma Management
Melanie Cole (Host): Welcome to Pediatrics in Practice with Children's Mercy Kansas City. I'm Melanie Cole. And here to highlight the new asthma guidelines, a paradigm shift in asthma management is Dr. Nadine Mokhallati. She's a Pediatric pulmonologist and the Medical Director of the Pulmonary Function Lab at Children's Mercy Kansas City. Dr. Mokhallati, thank you so much for being with us today. As we get into this topic and the new guidelines, tell us a little bit about the burden of asthma in kids and how common this is.
Dr Nadine Mokhallati: Hi, Melanie. And thank you for having me. So asthma is the most common chronic childhood disease. Just to kind of give you guys a sense of how prevalent it is, in 2018, the prevalence of asthma in US children younger than eighteen was actually 7.5%, so pretty high. And with higher proportions in the younger age group, kids ages five to fourteen, it was even more than that, it was around 8.5%.
Melanie Cole (Host): So then let's give a quick overview of the history of asthma management guidelines. What did they used to be? And what is different now?
Dr Nadine Mokhallati: So that is a really good question, because you really do need to know the history of asthma management and guidelines to know how much of a paradigm shift and how important these new guidelines are compared to what we've done in the past for decades really. So the two bodies that give us updated asthma guidelines every few years are the NAEPP, which is the National Asthma Education and Prevention Program, which is sponsored by the National Health Lung and Blood Institute and the National Institutes of Health.
The other body that gives us annual asthma guidelines is the Global Initiative for Asthma or GINA. There are some differences between these two bodies. The NAEPP again is sponsored by the NIH. It caters more to a US audience. It published its first report on the diagnosis and management of asthma back in 1991. And then there was a comprehensive revision in 1997. There was an updated selection of topics in 2002. And then, there was a report in 2007. And then we really didn't hear anything from the NAEPP until 2020, these most recent updates. So we went essentially 13 years without any updates from the NAEPP regarding asthma management. So the fact that they came out with new guidelines in 2020, it was huge.
The Global Initiative for Asthma on the other hand or GINA, this was established in 1993 and it was a collaboration between the WHO or the World Health Organization and the NIH, as a strategy for the diagnosis and management of asthma. And this GINA report is updated annually. So unlike the NAEPP where sometimes we can go over a decade without hearing any updates, GINA is actually updated and published annually. And it caters more to an international audience in addition to the US audience.
And then, I think the second part of your question, Melanie, was how are the new guidelines different from historically what we've done with asthma management? So the center of our discussion with patients is always you have your maintenance inhaler, your inhaled steroid that's typically once or twice a day, and you have your patient's rescue inhaler that is as needed. And that's what we've done. There's a lot of evidence to support the efficacy of this, obviously, of this strategy.
Now, the difference, that kind of paradigm shift is what we're calling it, is both GINA and the NAEPP guidelines are recommending using inhaled steroids as needed. So not only is your short-acting beta-agonist or your albuterol essentially your rescue inhaler, but you would add on inhaled steroids as a rescue inhaler as well, whether it's in the form of two separate inhalers, one having inhaled steroids and the other being your albuterol or in the form of SMART therapy, which is single maintenance and reliever therapy that uses the combination budesonide/formoterol in one inhaler, and that's the generic. There's a brand name out there as well. And the reason specifically we use budesonide/formoterol is because formoterol is, yes, it is a long-acting beta-agonist, but it's also the only rapid onset long-acting beta-agonist, so we can use it as a rescue. So that's really the major update in both guidelines, is again this idea of inhaled steroids don't necessarily have to be once or twice a day with a separate rescue inhaler, they can be used together as needed, or they can be used together in one inhaler as a maintenance and rescue inhaler.
Melanie Cole (Host): Thank you for that excellent comprehensive answer, Dr. Mokhallati. And for providers when they're counseling their patients, what you've just described can be a complex regimen for families to understand. And certainly for kids, once they learn how to manage their own illness and chronic illness, that's a whole different podcast on transitioning to adult, but for the parents, when these providers are counseling the families on these complex regimens, what do you suggest that they do? How do you suggest that they work with the families?
Dr Nadine Mokhallati: So that's a really good question, because, yes, this is a very exciting new way of managing asthma and it gives us a lot more flexibility in treating our patient's asthma. And I have to highlight here the importance of shared decision-making with the family. So when you talk to your asthma families, parents or kids with asthma, it's very important to present options to them depending on their age, depending on their asthma severity and depending on their day-to-day schedule and what they think is reasonable. So both GINA and the NAEPP really highlight this importance of shared decision-making with the families, because now you have more than one way of treating different severities of asthma. So again, take into account your patient's age, take into account their resources, take into account their lifestyles.
Having said that, there are many barriers to implementing some of these new strategies. The first and foremost is, unfortunately, up until this point, even though there's a lot of evidence behind this as-needed inhaled steroid strategy and the SMART strategy as well, it's still not technically FDA approved. And so, insurances here in the United States, for the most part, they will not cover more than one maintenance or steroid inhaler a month, which presents a problem if you're going to use this inhaler as both your maintenance inhaler and your rescue inhaler.
So one of the things I always counsel my patients try to get around that is, okay, if you are using, say, your budesonide/formoterol inhaler as part of SMART, which again means taking it as your maintenance inhaler, but also taking it as a rescue, even if you're not completely out of that inhaler by the end of the month and you still have puffs left on it, go ahead and refill anyways. And that way, you can kind of stockpile extra inhalers to keep on hand. So you can use in the future as needed if your asthma's acting up. So that's one of the main things I start talking to my patients about, specifically when I prescribe SMART.
The other big thing is remember, again, for decades, we've told our patients, this inhaler, "This albuterol inhaler is your rescue, this other inhaler is your maintenance." And now, suddenly you're telling them, "Oh, you don't need to do anything on a day to day basis. You can just do both of these as needed." And so what I found is it's not easy to let go of old habits where you identify albuterol as your rescue inhaler. And so I worry sometimes when we don't do enough education about this, that they are going to end up with just using albuterol and forgetting to use that second inhaler, the inhaled steroid, with it. So you really need to make sure you have a good written asthma action plan that you educate the family well, that we are going to be using both of these now, think of both of these as your rescue inhaler, because this strategy has been shown to decrease serious asthma exacerbations and hospitalizations as opposed to albuterol alone.
Melanie Cole (Host): What great information and such excellent points that you made about shared decision-making with the families, because this is something that they have to learn for life and teach each other and work together. So thank you for that. As we wrap up, what would you say are the key takeaways that primary care providers need to know about these new guidelines and the paradigm shift in asthma management?
Dr Nadine Mokhallati: I think the key takeaway is these new guidelines are quite a change from what we've done for years and years. They can be overwhelming, especially for pediatric providers, because unlike in the adult world where everyone is lumped into one group, in pediatrics, you have your preschool age group, which is the less than five-year-olds, you have your five to twelve years old and then the twelve to eighteen, so there's three different age groups that have three different sets of guidelines, which makes it a little bit more challenging for the pediatric provider. But it seems challenging at first, but I'd like providers to think of it more as they now have more tools, they have more options to offer families. And this really helps us bring the family into the management and decision-making more, because you can offer different ways of treating asthma, and see what would work best for them. We have more tools now, we have more options. And that shared decision-making with the family is the key to success in treating and managing any asthma patient.
Melanie Cole (Host): What an informative podcast. Thank you so much, Dr. Mokhallati, for joining us today and sharing your incredible expertise. And to refer your patient or for more information, please visit childrensmercy.org to get connected with one of our providers. This has been Pediatrics In Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.
New Asthma Guidelines: A Paradigm Shift in Asthma Management
Melanie Cole (Host): Welcome to Pediatrics in Practice with Children's Mercy Kansas City. I'm Melanie Cole. And here to highlight the new asthma guidelines, a paradigm shift in asthma management is Dr. Nadine Mokhallati. She's a Pediatric pulmonologist and the Medical Director of the Pulmonary Function Lab at Children's Mercy Kansas City. Dr. Mokhallati, thank you so much for being with us today. As we get into this topic and the new guidelines, tell us a little bit about the burden of asthma in kids and how common this is.
Dr Nadine Mokhallati: Hi, Melanie. And thank you for having me. So asthma is the most common chronic childhood disease. Just to kind of give you guys a sense of how prevalent it is, in 2018, the prevalence of asthma in US children younger than eighteen was actually 7.5%, so pretty high. And with higher proportions in the younger age group, kids ages five to fourteen, it was even more than that, it was around 8.5%.
Melanie Cole (Host): So then let's give a quick overview of the history of asthma management guidelines. What did they used to be? And what is different now?
Dr Nadine Mokhallati: So that is a really good question, because you really do need to know the history of asthma management and guidelines to know how much of a paradigm shift and how important these new guidelines are compared to what we've done in the past for decades really. So the two bodies that give us updated asthma guidelines every few years are the NAEPP, which is the National Asthma Education and Prevention Program, which is sponsored by the National Health Lung and Blood Institute and the National Institutes of Health.
The other body that gives us annual asthma guidelines is the Global Initiative for Asthma or GINA. There are some differences between these two bodies. The NAEPP again is sponsored by the NIH. It caters more to a US audience. It published its first report on the diagnosis and management of asthma back in 1991. And then there was a comprehensive revision in 1997. There was an updated selection of topics in 2002. And then, there was a report in 2007. And then we really didn't hear anything from the NAEPP until 2020, these most recent updates. So we went essentially 13 years without any updates from the NAEPP regarding asthma management. So the fact that they came out with new guidelines in 2020, it was huge.
The Global Initiative for Asthma on the other hand or GINA, this was established in 1993 and it was a collaboration between the WHO or the World Health Organization and the NIH, as a strategy for the diagnosis and management of asthma. And this GINA report is updated annually. So unlike the NAEPP where sometimes we can go over a decade without hearing any updates, GINA is actually updated and published annually. And it caters more to an international audience in addition to the US audience.
And then, I think the second part of your question, Melanie, was how are the new guidelines different from historically what we've done with asthma management? So the center of our discussion with patients is always you have your maintenance inhaler, your inhaled steroid that's typically once or twice a day, and you have your patient's rescue inhaler that is as needed. And that's what we've done. There's a lot of evidence to support the efficacy of this, obviously, of this strategy.
Now, the difference, that kind of paradigm shift is what we're calling it, is both GINA and the NAEPP guidelines are recommending using inhaled steroids as needed. So not only is your short-acting beta-agonist or your albuterol essentially your rescue inhaler, but you would add on inhaled steroids as a rescue inhaler as well, whether it's in the form of two separate inhalers, one having inhaled steroids and the other being your albuterol or in the form of SMART therapy, which is single maintenance and reliever therapy that uses the combination budesonide/formoterol in one inhaler, and that's the generic. There's a brand name out there as well. And the reason specifically we use budesonide/formoterol is because formoterol is, yes, it is a long-acting beta-agonist, but it's also the only rapid onset long-acting beta-agonist, so we can use it as a rescue. So that's really the major update in both guidelines, is again this idea of inhaled steroids don't necessarily have to be once or twice a day with a separate rescue inhaler, they can be used together as needed, or they can be used together in one inhaler as a maintenance and rescue inhaler.
Melanie Cole (Host): Thank you for that excellent comprehensive answer, Dr. Mokhallati. And for providers when they're counseling their patients, what you've just described can be a complex regimen for families to understand. And certainly for kids, once they learn how to manage their own illness and chronic illness, that's a whole different podcast on transitioning to adult, but for the parents, when these providers are counseling the families on these complex regimens, what do you suggest that they do? How do you suggest that they work with the families?
Dr Nadine Mokhallati: So that's a really good question, because, yes, this is a very exciting new way of managing asthma and it gives us a lot more flexibility in treating our patient's asthma. And I have to highlight here the importance of shared decision-making with the family. So when you talk to your asthma families, parents or kids with asthma, it's very important to present options to them depending on their age, depending on their asthma severity and depending on their day-to-day schedule and what they think is reasonable. So both GINA and the NAEPP really highlight this importance of shared decision-making with the families, because now you have more than one way of treating different severities of asthma. So again, take into account your patient's age, take into account their resources, take into account their lifestyles.
Having said that, there are many barriers to implementing some of these new strategies. The first and foremost is, unfortunately, up until this point, even though there's a lot of evidence behind this as-needed inhaled steroid strategy and the SMART strategy as well, it's still not technically FDA approved. And so, insurances here in the United States, for the most part, they will not cover more than one maintenance or steroid inhaler a month, which presents a problem if you're going to use this inhaler as both your maintenance inhaler and your rescue inhaler.
So one of the things I always counsel my patients try to get around that is, okay, if you are using, say, your budesonide/formoterol inhaler as part of SMART, which again means taking it as your maintenance inhaler, but also taking it as a rescue, even if you're not completely out of that inhaler by the end of the month and you still have puffs left on it, go ahead and refill anyways. And that way, you can kind of stockpile extra inhalers to keep on hand. So you can use in the future as needed if your asthma's acting up. So that's one of the main things I start talking to my patients about, specifically when I prescribe SMART.
The other big thing is remember, again, for decades, we've told our patients, this inhaler, "This albuterol inhaler is your rescue, this other inhaler is your maintenance." And now, suddenly you're telling them, "Oh, you don't need to do anything on a day to day basis. You can just do both of these as needed." And so what I found is it's not easy to let go of old habits where you identify albuterol as your rescue inhaler. And so I worry sometimes when we don't do enough education about this, that they are going to end up with just using albuterol and forgetting to use that second inhaler, the inhaled steroid, with it. So you really need to make sure you have a good written asthma action plan that you educate the family well, that we are going to be using both of these now, think of both of these as your rescue inhaler, because this strategy has been shown to decrease serious asthma exacerbations and hospitalizations as opposed to albuterol alone.
Melanie Cole (Host): What great information and such excellent points that you made about shared decision-making with the families, because this is something that they have to learn for life and teach each other and work together. So thank you for that. As we wrap up, what would you say are the key takeaways that primary care providers need to know about these new guidelines and the paradigm shift in asthma management?
Dr Nadine Mokhallati: I think the key takeaway is these new guidelines are quite a change from what we've done for years and years. They can be overwhelming, especially for pediatric providers, because unlike in the adult world where everyone is lumped into one group, in pediatrics, you have your preschool age group, which is the less than five-year-olds, you have your five to twelve years old and then the twelve to eighteen, so there's three different age groups that have three different sets of guidelines, which makes it a little bit more challenging for the pediatric provider. But it seems challenging at first, but I'd like providers to think of it more as they now have more tools, they have more options to offer families. And this really helps us bring the family into the management and decision-making more, because you can offer different ways of treating asthma, and see what would work best for them. We have more tools now, we have more options. And that shared decision-making with the family is the key to success in treating and managing any asthma patient.
Melanie Cole (Host): What an informative podcast. Thank you so much, Dr. Mokhallati, for joining us today and sharing your incredible expertise. And to refer your patient or for more information, please visit childrensmercy.org to get connected with one of our providers. This has been Pediatrics In Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. I'm Melanie Cole.