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Major German guidelines revision shifts asthma treatment focus

Asthma has long been associated with the use of inhalers to control symptoms, but new, updated guidelines created by the German Respiratory Society, with input from another 11 professional associations from both Austria and Germany, aim to change this, with the experts recommending anti-inflammatory therapy as the primary therapeutic option.

“For decades, we have known about medication that can 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 S2K guideline co-ordinator Dr Marek Lommatzsch, head senior physician of the Pulmonology Department at the University Medicine Rostock, Germany.

The authors have comprehensively revised the 2017 guideline, reports Medscape, while the evidence-based national disease management guideline (NVL) for general asthma care from 2020 was also amended.

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,” said 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 hyposensitisation, 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.”

With children, however, it’s a little different.

Dr Erika von Mutius, paediatrician and professor of paediatric 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, but said: “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.”

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.

Von Mutius said use of the FeNO test has not been established in many practices and outpatient clinics, and that the inflammatory marker is also subject to fluctuations.

Which biologic?

Despite treatment with the established therapies, asthma symptoms can persist in some people with severe forms of the condition.

Biologics are highly effective for these patients and 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 for severe asthma. Officially, almost any biologic can be taken into consideration, since the approvals overlap. Nevertheless, we have known that certain patients benefit hugely from certain biologics. A targeted choice should therefore be made,” said Lommatzsch.

Biologics were mentioned in the 2020 NVL, but not to the same extent as they are in the latest version.

“For first time, we have created an overview diagram for the individual choice of biologic: we have now set a standard,” said Lommatzsch.

Therapy with biologics has brought about rapid progress for adults, but Von Mutius anticipates challenges in approving such therapeutics for paediatric treatment.

Meanwhile, dupilumab is approved for children aged six months and older; unfortunately, the indication for this is atopic dermatitis, she said.

When using this therapy for paediatric patients, it is important to explain the options to parents and 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 chapter characterises the interrelation between asthma and mental health, differentiating 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 suffer under the everyday strain of having asthma, said Lommatzsch. So it is important to educate patients and family on how to make a strength out of this supposed weakness – the asthmatic illness.

A procedure has been established for this and its key points summarised in the guideline.

Other updates cover asthma in different contexts, such as in pregnant women, and also address adrenal insufficiency as a side effect of the use of steroids over many years.

In addition, there’s a chapter on digital apps that can help with diagnostics and medical history.

Lommatzsch highlighted a new tool. “By using 15 key points summarised 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.”

 

Medscape article – New German Guidelines Change the Paradigm for Asthma (Open access)

 

See more from MedicalBrief archives:

 

South African childhood asthma guidelines 2021

 

Clinicians ignore international guidelines on minimum effective dose for asthma

 

Urgent need to improve asthma control worldwide – global study

 

Asthma management key to reducing SA's high childhood mortality – global report

 

Inhaled steroids promote secretions which block treatment in severe asthma patients – US study

 

 

 

 

 

 

 

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