Consensus on mild asthma management: results of a modified Delphi study

Figures & data

Figure 1. Research procedure.

Table 1. Participants’ current and preferred treatments for patients with mild asthma (Delphi survey 1).

Q: Thinking about all your patients diagnosed with mild asthma, please indicate what percentage are currently prescribed each of the following treatments.
Treatment	Patients (%)
ICS + as-needed SABA	30
As-needed ICS-formoterol	25
Daily ICS + LABA + as-needed SABA	13
As-needed SABA	11
Daily LTRA + as-needed SABA	3
Daily ICS + LTRA + as-needed SABA	2
As-needed ICS and SABA	2
Other*	13
Q: What is your preferred treatment regimen for patients diagnosed with mild asthma (i.e. patients whose asthma can be well controlled with Step 1 or Step 2 treatment, as defined by GINA)?
Treatment	Patients physicians (%)
ICS + as-needed SABA	38
As-needed ICS-formoterol	44
Daily ICS + LABA + as-needed SABA	6
As-needed SABA	–
Daily LTRA + as-needed SABA	–
Daily ICS + LTRA + as-needed SABA	–
As-needed ICS and SABA	–
Other*	13

*Listed as either daily ICS + as-needed ICS-formoterol or as-needed ICS + SABA.

ICS: Inhaled corticosteroid; LABA: long-acting beta-agonist; LTRA: leukotriene receptor antagonist; SABA: short-acting beta-agonist.

Figure 2. Most important factors driving treatment choices for mild asthma.

Table 2. Summary of scientific workshop discussions.

Theme discussed	Summary of discussion
Regular dosing versus variable dosing in asthma management: the clinical evidence	General acceptance that regular maintenance dosing is the best asthma management strategy in mild asthma due to better outcomes in asthma control and inflammation suppression. Results of RCTs unequivocally stated that regular ICS was superior or equivalent to as-needed ICS-formoterol for asthma control parameters General agreement that the clinical studies supporting the variable dosing strategy were not conducted in GINA step 1 patients, questioning their scientific validity in relation to patients with mild asthma The issue of real-world compliance with regular dosing, and use of a variable dosing strategy as an alternative approach, was highlighted by several participants. The question remains whether a variable dosing regimen would ensure adherence. The importance of considering both asthma control and severe exacerbation risk was emphasized
GINA update for mild asthma and comparison with GEMA 5.0 guidelines	Most agreed that GINA is a good document about asthma but is an opinion statement, not a guideline; national guidelines are more relevant in individual countries General agreement that GINA, based on literature review and not GRADE methodology, would benefit from being more balanced in its evidence evaluation to reach consensus recommendations GEMA 5.0 developed by a multidisciplinary, representative team; uses Delphi panel evaluations and is accredited by AGREE II In GEMA, three alternatives recommended for Step 1 treatment: SABA only, as-needed ICS-formoterol or as-needed SABA + ICS PRN. Step 2 (persistent mild asthma) recommends regular daily low dose ICS plus as-needed SABA
Discussion on approach by other guidelines	Other treatment guidelines taken a consensus- and evidence-based approach; some do not recommend as-needed ICS-formoterol at all for mild asthma (Japanese, BTS, NEAPP guidelines) and some recommend as-needed ICS-formoterol as an alternative to regular ICS in mild asthma (Thai and Canadian guidelines) Guidelines provide consensus- and evidence-based guidance at a group level; individual patient requirements should also be considered

BTS: British Thoracic Society; GEMA: Spanish Guideline on the Management of Asthma; GINA: Global Initiative for Asthma; ICS: Inhaled corticosteroid; RCT: Randomized controlled trial; SABA: short-acting beta-agonist.

Figure 3. Approach to mild asthma treatment. ICS: inhaled corticosteroid.

Figure 4. Benefits of asthma control treatment regimens. ICS: inhaled corticosteroid.

Figure 5. Final consensus statements. ICS: inhaled corticosteroid.

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