Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines.
Luis A Perez-de-LlanoDavid Dacal-RivasNagore Blanco CidIrene Martin RoblesPublished in: Journal of asthma and allergy (2021)
Despite recent advances in therapy, a substantial proportion of asthmatics remain not well controlled. The classical stepwise approach to pharmacological therapy in adult asthma recommends that treatment is progressively stepped up by increasing the inhaled corticosteroid (ICS) dose or by adding another controller medication- to achieve symptom control and reduce the risk of exacerbations, and stepped down after a period of control. In general, asthma guideline recommendations do not reflect that there are significant differences between ICS in terms of potency. Moreover, they do not consider efficacy and safety separately, incorrectly assuming that "low" and "high" dose categories inevitably correspond with low and high risk of systemic effects. Another point of criticism is the fact that guidelines do not take into account the inflammatory profile of the patient, although substantial groups of patients with mild and moderate asthma have little evidence of "T2-high" inflammation, and by extension are likely to show a poor response to ICS treatment. On the other hand, the latest version of the Global Initiative for Asthma (GINA) equally recommends regular ICS and ICS/formoterol as needed to prevent exacerbations in step 2 patients, without taking into consideration that the therapeutic objectives (exacerbations, symptoms) may differ between individual patients and that different goals may warrant distinct treatment strategies. In this review, we bring to the table several controversial issues concerning asthma treatment and suggest an alternative proposal that takes into consideration the potential side effects of high ICS doses, the patient's inflammatory profile and the therapeutic goals to be achieved.
Keyphrases
- chronic obstructive pulmonary disease
- lung function
- end stage renal disease
- cystic fibrosis
- allergic rhinitis
- high dose
- oxidative stress
- ejection fraction
- newly diagnosed
- chronic kidney disease
- clinical trial
- prognostic factors
- case report
- peritoneal dialysis
- emergency department
- air pollution
- public health
- randomized controlled trial
- combination therapy
- bone marrow
- climate change
- stem cells
- cell therapy
- stem cell transplantation
- patient reported