Dr Megan Althoff on How, Why the GINA, ERS/ATS Guidelines Differ

December 30, 2020

One guideline focuses on managing severe asthma and the other begins with recommendations for mild intermittent asthma before increasing based on disease severity, noted Megan Althoff, MD, PhD, University of Colorado.

One guideline focuses on managing severe asthma and the other begins with recommendations for mild intermittent asthma before increasing based on disease severity, noted Megan Althoff, MD, PhD, second-year fellow, University of Colorado, Division of Pulmonary Sciences and Critical Care Medicine.

Transcript

How do the various asthma guidelines differ? What should future guidelines address?

The ERS/ATS [European Respiratory Society/American Thoracic Society] guidelines focus really just on the management of severe asthma, so in that way [they are] different from GINA [Global Initiative for Asthma], which is going to start you with a mild intermittent asthma and works your way up. So ERS/ATS was focused on 6 questions around severe asthma management.

I think one of the biggest differences between the ERS/ATS and GINA is especially with the IL-5 [interleukin-5] and IL-5 receptor antagonists—mepolizumab, reslizumab, and benralizumab—the ERS/ATS guidelines think they're worth trying in patients who have peripheral eosinophils greater than 150, whereas GINA recommends choosing any of those therapies if your patient has a peripheral eosinophil count over 300.

So the patient sitting in front of you who's kind of in between those 2 ranges, GINA would say, if you will, there’s a lower chance this is going to be successful in your patient, whereas when ERS/ATS reviewed the literature, they think there's not enough strong data to suggest that you shouldn't try it in an uncontrolled patient who has slightly lower peripheral eosinophils.

Similarly, with dupilumab, which is the anti–IL-4 receptor alpha subunit antagonist, ERS/ATS recommends trying that in any patient, regardless of their peripheral eosinophil count, if they're uncontrolled on an oral corticosteroid, whereas GINA says to try it if they have greater than 150 eosinophils. So that's practically a pretty big difference.

The other difference was the ERS/ATS guidelines talked about the long-acting antimuscarinics, or tiotropium specifically—that’s the one most thoroughly studied—and they had recommended trying that in patients who are uncontrolled at GINA’s step 4 and 5, whereas GINA recommends considering it more in non-Th2 asthmatics and if you're uncontrolled at step 5.

So ERS/ATS is a little bit more pro starting a LAMA [long-acting muscarinic antagonist] a little bit earlier in therapy and for more patients. Those are kind of the biggest differences, I think, between the 2 guidelines.