Jennifer Namazy, MD, FAAAAI

This document is a result of a working group report comprised primarily of pulmonologists but also a multidisciplinary panel of obstetricians, pharmacists and primary care providers. It is unique in its multidisciplinary approach to providing recommendations on the management of asthma in pregnant patients.

The last U.S. Working Group report through the National Asthma Education and Prevention Program (NAEPP) was published in 2004, but there have been other recommendations such as the Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention guidelines in 2020. This particular Dutch report distinguishes itself from GINA in that they use a GRADE method to measure the strength of evidence.

Although this document does not provide much in terms of novel information, it does provide a good review for clinicians in terms of evidence-based strategies to manage asthma among our pregnant patients. It is a great reminder to clinicians that asthma is the most common chronic lung disease to affect pregnant women and that more than one-third of patients experience worsening asthma during pregnancy. This is a great resource that provides evidence-based information in a clear and concise way.

Some key takeaways that I find especially important:

• The recommendation on preconception counseling: This is a “window of opportunity,” as the authors state, to identify risk factors for worsening asthma and begin education on the importance of treating asthma during pregnancy. This will begin the shared decision-making process and can improve adherence and outcomes for both mother and baby.
• Addressing combined single maintenance and reliever therapy (SMART): Although there are no studies addressing what we call “SMART therapy” in this population of patients, the authors do point out that the potential advantages in this population of patients is the chance for improvement in adherence and reduction in need of short-acting B-agonists.
• Providing a flowchart on monitoring asthma during pregnancy: This chart stresses the importance of a multidisciplinary approach to care including obstetricians and PCPs. Multidisciplinary approaches to care for pregnant asthmatics have been shown to improve asthma control and adherence during pregnancy, which can lead to improved outcomes.

The next steps are to continue to identify and focus on research that can fill the knowledge gaps regarding the safety of medications used to treat asthma during pregnancy, such as SMART therapy, for example. Although most medications have reassuring safety profiles, we still have a long way to go, especially with increasing asthma biologic use.

Reference:

GINA global strategy for asthma management and prevention. https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. Updated 2020. Accessed June 25, 2024.

Vanessa Murphy, PhD

The Dutch Multidisciplinary Practice Guideline on Asthma and Pregnancy lays out key recommendations which are consistent with previously reported guidelines and recommendations for asthma management in pregnancy. There is a focus on multidisciplinary management and risk identification to help clinicians determine the level of monitoring required for an individual woman with asthma in pregnancy. By naming clinicians from a range of specialties in these guidelines (pulmonologists, allergists, obstetricians, midwives, respiratory nurses, pharmacists and general practitioners), the authors have been able to give clear examples of how a multidisciplinary team approach may work, with the goal being to provide consistent advice from all involved in a woman’s care. This is greatly needed, particularly when it comes to advice about medication safety.

The key messages related to medication use are:

• Inhaled corticosteroids (ICS) should be continued during pregnancy when a woman has well-controlled asthma, and in the case of uncontrolled asthma, ICS treatment should be considered or reconsidered.
• While clinicians should exercise caution when stepping down maintenance ICS use in pregnancy, biomarkers such as fractional exhaled nitric oxide are mentioned as being potentially useful during dose titration.
• During exacerbations, women with asthma should be treated as if they were not pregnant with regard to oral corticosteroid treatment.
• The only biologic with published safety data is omalizumab. Other biologics should be considered in the context of individual case discussion by a multidisciplinary team.

One area which has received new attention in these guidelines is that of risk factors for negative outcomes, such as asthma exacerbations. The authors proposed uncontrolled asthma or moderate/severe asthma as “leading risk factors,” whereas others including maternal age, smoking, BMI, anxiety/depression, multiparity, short-acting B-agonist overuse and ICS nonadherence are considered “supporting risk factors.” Risk factor analysis is suggested as a useful tool for deciding the level of monitoring required during pregnancy.

This section is followed by the pragmatic suggestion that follow-up of pregnant women with asthma be conducted for those with risk factors, rather than for all women every 4 to 6 weeks during pregnancy. A helpful flow chart is provided which integrates midwifery care with asthma care. The role of the midwife here is to ask about asthma symptoms at least every trimester and, if these exist, to refer to primary or secondary care for further asthma follow-up.

More research is needed on the safety of biologics for asthma treatment in pregnancy, and women are encouraged to sign up to be part of pregnancy exposure registries, which are essential for collecting new data on these relatively uncommon drug exposures.

Greater understanding of risk factors, the subgroups of women who would benefit from more intense monitoring and what this monitoring would look like in various clinical contexts, is also needed.