Paradigm Shift in Management of Mild Asthma

Stephen Reeves, MD, PhD
Seattle Children’s Pulmonary and Sleep Medicine team

Asthma is the most common chronic disease of childhood throughout the world and exacts a high toll in terms of healthcare utilization and family and school disruption.

About 120,000 children in Washington state have asthma. Typical symptoms include chronic cough, wheezing, dyspnea and chest tightness. Allergens and/or viral infections are often triggers. Children whose asthma is poorly controlled are at higher risk for exacerbation with virus – something worth noting given the presence of COVID-19 this season.

Don’t use SABA alone – GINA 2019 recommendation

Last April, the Global Initiative for Asthma (GINA 2019) recommended that short-acting bronchodilators (SABA) not be used alone for mild asthma. This was the most fundamental change in asthma management in more than 30 years.

Instead, adolescents and adults with mild asthma should receive symptom-driven relief as needed with a combination inhaler that includes formoterol (a fast onset, long-acting bronchodilator or LABA) and an inhaled corticosteroid (ICS). Recommendations in children under 12 include possibly adding a low-dose ICS in addition to SABA administration for acute exacerbations.

Misconceptions about inhaled steroids and LABAs

Some providers and pharmacists resist issuing long-acting bronchodilators (LABA) because of prior FDA black box warnings issued when LABAs were used alone.

The FDA removed the black box warning on LABAs in 2017 after new evidence showed they are safe – and effective – when used in conjunction with ICS. These medications are formulated in combination inhalers.

However, we still see children – in the clinic and hospital – who experienced an exacerbation after prescriptions including a LABA were not filled and whose families didn’t discuss with the prescribing provider. This highlights the continuing need for education on the most current recommendations.

Hesitancy about inhaled steroids often centers on concerns about side effects. It is important to note that ICS do not have the same side effects as systemic steroids. Consistent use of ICS medications reduces exacerbations and the need for systemic steroids.

When to refer:

Asthma is often successfully managed in the primary care setting. You may consider referring when:

  • Treatment isn’t meeting its goals.
  • There is concern for a confounding/alternative diagnosis.
  • The symptoms are atypical.
  • Specialized diagnostic testing is needed.
  • The patient or family needs additional education.
  • The patient desires confirmation of the diagnosis.
  • There are life-threatening exacerbations.