The Global Initiative for Asthma (GINA) has taken a clear position in its 2021 update [1]: Cases of mild bronchial asthma should also receive an initial inhaled steroid in the future, whereas short-acting beta-2-mimetics (SABA) have lost much of their importance.
In the updated recommendations, there are now two paths, called tracks, that can be followed therapeutically. On Track 1, a fixed combination of ICS and formoterol is administered as acute medication at all stages. The long-acting beta-2 agonist (LABA) is suitable for demand therapy due to its rapid onset of action. In combination, patients are also automatically given a stroke inhaled corticosteroid, which is why GINA recommends this when symptoms flare up.
The application as pure demand therapy is possible on levels 1 and 2, from level 3 a permanent therapy is indicated (Fig.1). At the higher levels 3 to 5, the advice of the GINA authors is to use the same preparation for maintenance and on-demand therapy to eliminate possible confusion on the part of the patient in the event of an attack. Track 1 is clearly prioritized in the GINA update recommendation, especially since, according to the authors, severe exacerbations requiring oral steroid administration can occur even in mild asthma.
SABA associated with risks
The alternative to the ICS/LABA combination is still SABA as an as-needed therapy. However, in this track 2, patients should still also always inhale an ICS at the same time. The background to this is to avoid patients getting the idea of treating their asthma exclusively with a SABA right from the start. However, this approach entails two risks: On the one hand, patients often lack the necessary compliance with ICS. And on the other hand, even short-term SABA use over 14 days already carries the risk of increased bronchial hyperresponsiveness. >3 SABA prescriptions within 12 months increase the risk of severe exacerbations. For this reason, Track 2 is clearly positioned as a second choice option behind Track 1.
SABA plus ICS on demand should be considered only if the patient can be expected to reliably inhale the ICS to the SABA and ICS/formoterol is not available, the authors said. If the therapy is effective and the asthma is well controlled over two to three months, the physician and patient can decide together whether to reduce the dosage.
Literature:
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2021 update); https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf.
InFo PNEUMOLOGY & ALLERGOLOGY 2021; 3(4): 5.
