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Review
. 2021 Mar 12:14:207-217.
doi: 10.2147/JAA.S266999. eCollection 2021.

Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines

Luis Pérez de Llano  1 , David Dacal Rivas  1 , Nagore Blanco Cid  1 , Irene Martin Robles  1
Affiliations
Review

Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines

Luis Pérez de Llano et al. J Asthma Allergy. .

Abstract

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.

Keywords: asthma; asthma endotype; asthma phenotype; asthma treatment; personalized medicine.

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Conflict of interest statement

Dr. Pérez de Llano reports grants, personal fees and non-financial support from AstraZeneca, personal fees and non-financial support from GSK, grants and personal fees from TEVA, personal fees and non-financial support from Novartis, personal fees and non-financial support from Chiesi, personal fees and non-financial support from Boehringer, personal fees from Sanofi, personal fees from Menarini, personal fees and non-financial support from Mundipharma, grants and personal fees from Esteve, personal fees from ROVI, personal fees from BIAL, personal fees from MSD, personal fees from TECHDOW PHARMA, non-financial support from FAES, outside the submitted work. The authors report no other conflicts of interest in this work.

Figures

Figure 1
Figure 1
A clinical example of therapeutic goals and treatable traits.
Figure 2
Figure 2
Suggested approach to mild asthma treatment.
Figure 3
Figure 3
Suggested approach to moderate to severe asthma treatment.
See this image and copyright information in PMC

References

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