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Managing Asthma in Adolescents and Adults2020 Asthma Guideline Update From the National Asthma Education and Prevention Program

Educational Objective
To review the clinical management of adolescents and adults with asthma.
1 Credit CME

Importance  Asthma is a major public health problem worldwide and is associated with excess morbidity, mortality, and economic costs associated with lost productivity. The National Asthma Education and Prevention Program has released the 2020 Asthma Guideline Update with updated evidence-based recommendations for treatment of patients with asthma.

Objective  To report updated recommendations for 6 topics for clinical management of adolescents and adults with asthma: (1) intermittent inhaled corticosteroids (ICSs); (2) add-on long-acting muscarinic antagonists; (3) fractional exhaled nitric oxide; (4) indoor allergen mitigation; (5) immunotherapy; and (6) bronchial thermoplasty.

Evidence Review  The National Heart, Lung, and Blood Advisory Council chose 6 topics to update the 2007 asthma guidelines based on results from a 2014 needs assessment. The Agency for Healthcare Research and Quality conducted systematic reviews of these 6 topics based on literature searches up to March-April 2017. Reviews were updated through October 2018 and used by an expert panel (n = 19) that included asthma content experts, primary care clinicians, dissemination and implementation experts, and health policy experts to develop 19 new recommendations using the GRADE method. The 17 recommendations for individuals aged 12 years or older are reported in this Special Communication.

Findings  From 20 572 identified references, 475 were included in the 6 systematic reviews to form the evidence basis for these recommendations. Compared with the 2007 guideline, there was no recommended change in step 1 (intermittent asthma) therapy (as-needed short-acting β2-agonists [SABAs] for rescue therapy). In step 2 (mild persistent asthma), either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy are recommended. Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) is recommended as the preferred therapy for moderate persistent asthma in step 3 (low-dose ICS-formoterol therapy) and step 4 (medium-dose ICS-formoterol therapy) for both daily and as-needed therapy. A short-term increase in the ICS dose alone for worsening of asthma symptoms is not recommended. Add-on long-acting muscarinic antagonists are recommended in individuals whose asthma is not controlled by ICS-formoterol therapy for step 5 (moderate-severe persistent asthma). Fractional exhaled nitric oxide testing is recommended to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma. Allergen mitigation is recommended only in individuals with exposure and relevant sensitivity or symptoms. When used, allergen mitigation should be allergen specific and include multiple allergen-specific mitigation strategies. Subcutaneous immunotherapy is recommended as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. Sublingual immunotherapy is not recommended specifically for asthma. Bronchial thermoplasty is not recommended as part of standard care; if used, it should be part of an ongoing research effort.

Conclusions and Relevance  Asthma is a common disease with substantial human and economic costs globally. Although there is no cure or established means of prevention, effective treatment is available. Use of the recommendations in the 2020 Asthma Guideline Update should improve the health of individuals with asthma.

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Article Information

Corresponding Author: Michelle M. Cloutier, MD, Departments of Pediatrics and Medicine, UCONN Health, 263 Farmington Ave, Farmington, CT 06030 (cloutier@uchc.edu).

Accepted for Publication: October 26, 2020.

Published Online: December 3, 2020. doi:10.1001/jama.2020.21974

Author Contributions: Dr Cloutier had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cloutier, Dixon, Krishnan, Lemanske, Pace.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Cloutier, Dixon, Krishnan, Lemanske, Pace.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Cloutier, Krishnan, Lemanske.

Supervision: Cloutier, Lemanske.

Conflict of Interest Disclosures: Dr Cloutier reported having a family member employed by Regeneron. Dr Dixon reported receiving a study medication from MitoQ and receiving assistance from a Boehringer Ingelheim medical writer for an article published in 2019 (not related to the update topics). Dr Krishnan reported receiving research funding from the National Heart, Lung, and Blood Institute (NHLBI), Patient-Centered Outcomes Research Institute, Regeneron, Sergey Brin Family Foundation, and Inogen/ResMed for studies not related to the update topics and receiving consulting fees from the Critical Path Institute for work related to developing asthma symptom questionnaires and from Sanofi for serving on an independent data monitoring. Dr Lemanske reported receiving grants from the NHLBI, the National Institutes of Health, Childhood Origins of Asthma (COAST), and AsthmaNet; receiving a National Institutes of Health Clinical and Translational Science Award; and receiving personal fees from Louisiana State University, Elsevier, UpToDate, the Japanese Society of Allergy, the Asia Pacific Association of Allergy, Asthma, and Clinical Immunology and the Asia Pacific Association of Pediatric Allergy, Respirology, and Immunology, Scientific Consultant, the Food Allergy Research and Education Network, and Sciolta Inc. Dr Pace reported serving on an advisory group (1-time meeting) for Mylan concerning revefenacin; being a coinvestigator on grants from the NHLBI, the National Institute of Mental Health, the National Institute on Aging, the National Center for Advancing Translational Sciences, the Centers for Disease Control and Prevention, Tabula Rosa Health Care, and Boehringer Ingelheim for projects not related to the review topics; and receiving grants from the Patient-Centered Outcomes Institute related to asthma therapy but not specifically related to the review topics; he or his wife hold stock in Johnson & Johnson, Eli Lily, Novo Nordisk, Pfizer, Amgen, Gilead, and Novartis. Dr Schatz has received research grants to his institution from Merck, ALK, and Teva; honoraria from UpToDate; and a stipend from the American Academy of Allergy, Asthma, and Immunology for his position as editor in chief of the Journal of Allergy and Clinical Immunology: In Practice.

Funding/Support: The 2020 Asthma Guideline Update report was funded by the NHLBI of the National Institutes of Health.

Role of the Funder/Sponsor: The NHLBI determined the need to update recommendations, contracted with the Agency for Healthcare Research and Quality to select the organizations responsible for conducting the systematic reviews based on the key questions that were developed by the National Heart, Lung and Blood Advisory Council, selected the expert panel members, and provided administrative support and oversight. The expert panel designed and conducted the approach to the review of the evidence; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the guideline. The updated guidelines were accepted by the National Asthma Education and Prevention Program Coordinating Committee and cleared by the National Institutes of Health.

Additional Contributions: We are grateful to our colleagues on the expert panel; to James P. Kiley, PhD, director, Division of Lung Diseases, NHLBI, and George A. Mensah, MD, director, Center for Translation Research and Implementation Science, NHLBI, for support and encouragement; to Susan Shero, RN, BSN, MS, and Michelle Freemer, MD, MPH, both from the NHLBI, for technical, administrative and editorial support; to Shahnaz Sultan, MD, MHSC, AGAF, University of Minnesota, for expert guidance on using GRADE; to Lenora Johnson, DrPH, MPH, director, Office of Science Policy, Engagement, Education, and Communications, NHLBI, for work on the patient/caregiver focus groups; and to Westat, which provided technical and administrative support. We are also grateful for the comments from the National Asthma Education and Prevention Program Coordinating Committee members, professional societies, the public, nonprofit organizations, and industry. No compensation outside of regular salary was received by any named contributor.

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