According to GINA 2019, there is a fundamental change to the management of mild asthma. In this revision, the treatment of asthma with short-acting beta agonists (SABA) alone is no longer recommended for adults and adolescents, which is supported by several studies. Adverse events related to SABA include; a decrease in bronchodilation and bronchoprotection, increased allergic response and eosinophilic airway inflammation. Low-dose ICS are highly effective, reducing symptoms and the risk of hospitalisation and death. However, ICS-containing medications are under-used. GINA consider values and preferences of high importance in mild asthma. Avoiding SABA-only-treatment and the need for daily ICS provides a consistent message of symptom relief and risk reduction, making use of normal patient behaviour for prevention. GINA also points out several evidence gaps, such as other populations (children, pregnant women, patients with infrequent symptoms), clinical contexts, shared decision-making (discussing with patients) and policy-makers (eg access to medication).
There are still significant evidence gaps in the management of children and adolescents with asthma. Concerns highlighted in the management of mild asthma in adults and adolescents are also relevant for children. Collaborative working is crucial to improve the understanding and management of severe asthma in children. Adult studies should include younger adolescents in a sufficient number and pre-specified sub-group analysis. Finally, there are unmet needs for improved therapies in preschoolers, where phenotyping approaches show promise.
According to GINA, statements have been presented in the management of severe asthma in adults for 2020. In patients with type 2 severe asthma receiving treatment with ICS, add-on therapy with an anti-type 2 biologic such as; (mepolizumab, benralizumab or dupilumab) is corticoid-sparing and reduces exacerbations. In patients with type 2 severe asthma and frequent exacerbations despite high dose ICS+LABA, add-on therapy with the following biologics have been shown to be efficacious and safe: omalizumab in severe allergic asthma; mepolizumab, reslizumab (IV) and benralizumab in severe eosinophilic asthma; dupilumab in severe type 2 asthma. Head-to-head comparative effectiveness pragmatic trials in type 2 severe asthma are urgently needed. In this sense, reference has been made to the PREDICTUMAB 01 TRIAL (Predictive factors of response to omalizumab in allergic and eosinophilic severe asthma), a multicentre pragmatic trial in Belgium and Europe.