Use of Guidelines to Classify Asthma

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI:Dr White, you alluded earlier to the GINA [Global Initiative for Asthma] guidelines, and because we’re talking about severe asthma, difficult-to-manage asthma, are there any metrics that you use or can point us toward that can help classify those endotypes or the severity level of the patient with asthma who’s difficult to treat?

Andrew White, MD: We all probably did our training around the same time, and back then, if you asked 10 different allergists how to define severe asthma, you might get 10 different answers because there was a lot of uncertainty. What are we going to stratify if we’re going to call it severe? There was a need for a definition on the benchmark we’re going to use to define severe asthma. The GINA guidelines in 2021 offered a definition, and this has now become a standardized way for us to think about a benchmark. We talked earlier about some of the inhaler therapies, the inhaled steroids and the long-acting beta-agonists [LABAs], and those are going to be the core pharmacotherapy options we’re going to be using in our patients with asthma. As we move up the list, the strength of those medications will end up at some point on a high-dose inhaled corticosteroid [ICS] and a long-acting beta-agonist combination. And if a patient on that combination still has uncontrolled asthma, they’re still having symptoms, still having exacerbations, still having impairment with work or function, that’s severe asthma. So high-dose ICS, LABA, and uncontrolled asthma. But the other part of the definition is that you require staying at that level to maintain control. So, you’re taking the high-dose ICS and LABA and you’re doing great. You come back in 3 to 6 months to see Dr Chase and you decide you’re going to step back down, which is appropriate. You step back down on their therapy, and within 2 or 3 months there’s an exacerbation or they’re losing symptom control, and you have to go back up to the high-dose ICS and LABA. That also is severe asthma. So that’s the main definition, and I like that definition. It helps us separate the patients we need to be paying more attention to from the rest.

Transcript edited for clarity