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Phenotype-Guided Asthma Therapy: An Alternative Approach to Guidelines

Authors Pérez de Llano L, Dacal Rivas D, Blanco Cid N, Martin Robles I

Received 10 December 2020

Accepted for publication 18 February 2021

Published 12 March 2021 Volume 2021:14 Pages 207—217


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Amrita Dosanjh

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

Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo. C/ Doctor Ulises Romero, nº 1, Lugo, 27003, Spain

Correspondence: Luis Pérez de Llano
Head of the Pneumology Service, Lucus Augusti University Hospital, EOXI Lugo, Monforte, Cervo, C/Doctor Ulises Romero, nº 1, Lugo, 27003, Spain
Tel +34 982296000
Email [email protected]

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 treatment, asthma phenotype, asthma endotype, personalized medicine

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