An independent in‐depth analysis proposing adjusted Global Initiative on Asthma Step 1–2 treatment suggestions

Abstract

The Global Initiative on Asthma (GINA) strategy included major changes for the treatment of mild asthma in the 2020 version that are even taken to the next level in 2021, leaving a preferred track with only rescue therapy with inhaled corticosteroid and formoterol (ICS‐FORM) for steps 1–2 in 12+ years old. It has been questioned how solid the evidence behind these recommendations is. We decided to independently conduct an in‐depth analysis of published evidence based on a comprehensive evaluation of original articles and related appendices and publications, including quality of evidence and risk of bias per article. We first defined the major asthma treatment goals and proceeded to review how these were met in publications referenced in the main asthma guidelines. For patients with GINA (2021) Step 1 characteristics, the analysis supports GINA's decision to avoid SABA monotherapy and to prefer ICS‐FORM rescue with an alternative ICS rescue every time a SABA is used for ≥12 years, even though evidence is extrapolated from step 2 patients. For 6‐ to 11‐year‐olds, we propose to consider ICS‐FORM rescue as an alternative, as its use has been approved in this age group, be it not as rescue medication. For patients with GINA 2021 Step 2 characteristics, our proposal slightly differs from GINA 2021. We propose to continue avoiding the separate use of SABA, using ICS rescue whenever a fast‐acting bronchodilator is taken (even with ICS maintenance). Also, the superiority of ICS‐FORM rescue over classical step 2 treatment is not uniform and year‐long experience is lacking. Consequently, for now, both treatment options seem equal: ICS‐FORM rescue or ICS maintenance with SABA (+ICS) rescue. For 6‐ to 11‐year‐olds, ICS rescue every time a SABA is used has the advantage of lower total ICS dose; as alternative we suggest ICS‐FORM rescue. The best treatment option depends on patient characteristics and treatment goals. Recommendations should be reviewed as soon as new evidence becomes available.

Landscape of short‐acting beta‐agonists (SABA) overuse in Europe

“…54 All these recommendations are made for adult and adolescent asthma patients, but based on the good clinical results of the use of a combination as reliever medication, it has also been proposed to include the child population in this recommendation. 54,55 However, more real-world studies in children are needed to get a real insight into the impact of these therapeutic recommendations in this specific group. 56 The SABINA program and other recent studies in European countries clearly show that excessive use of SABA (≥3 canisters dispensed in a year) remains a reality in Europe and is a potential risk factor for exacerbations, regardless of ICS.…”

“…All these recommendations are made for adult and adolescent asthma patients, but based on the good clinical results of the use of a combination as reliever medication, it has also been proposed to include the child population in this recommendation 54,55 . However, more real‐world studies in children are needed to get a real insight into the impact of these therapeutic recommendations in this specific group 56 …”

Guía de dermatitis atópica para México (GUIDAMEX): lineamientos usando metodología ADAPTE

“…Como se ha experimentado con otras guías 162,163 , una estrategia para crear la expectativa de conocer lo que GUIDAMEX abarca es enviar un cuestionario electrónico en el que se aborden los puntos principales del contenido a los miembros de las sociedades participantes. La finalidad es doble: por un lado despertar el interés hacia al contenido de MIA, y, por otro lado, evidenciar en qué aspectos podría mejorarse el conocimiento y en cuáles se debe enfocar la educación médica continua.…”

On-Demand ICS + FABA Combinations in 6–11-Year-Old Children

“…It was not until 2019 that an important amendment was made in the Global Initiative for Asthma (GINA) and the recommendation was to add an ICS to β2-agonist for the treatment of acute symptoms, already from STEP 1 onward. With such a treatment schedule, a decrease in the risk of exacerbations and in the use of oral corticosteroids (OCS) has been demonstrated in adolescent and adults [8,9]. As there was very little evidence for such therapy in children, the changes were only recommended in adolescents-adults.…”