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a man asthma inhaler imageDecember 1 2017

NICE new guidelines on asthma, addressing diagnosis, monitoring and the management of chronic asthma, have had a mixed reception.

The Primary Care Respiratory Society UK (PCRS) “is concerned that the new NICE guideline will create uncertainty for primary care clinicians, because in some areas they recommend a different approach to the BTS/SIGN (British Thoracic Society and Scottish Intercollegiate Guidelines Network) guideline, which has set the evidence based standard for the UK since 2003.”

Asthma UK’s in-house GP, Dr Andrew Whittamore, has summarised the most significant changes for adults and children over the age of 5 years:

  • Diagnostic tests, as well as history taking, should be carried out before initiating pharmacotherapy, unless there is an urgent acute need for medication.
  • Diagnostic testing should normally use a combination of objective tests, such as spirometry, fractional exhaled nitric oxide (FeNO) and peak flow testing;
  • People who are not having symptoms controlled adequately by a steroid preventer inhaler alone should be offered an oral leukotriene receptor antagonist (LTRA) alongside a steroid preventer for 1-2 months to see if it makes a difference, rather than using a combination inhaler of a steroid and long acting beta agonist.

People who are already on a combination inhaler with well-controlled symptoms will continue their treatment. For infants and young children, the approach to diagnosis and management will continue as a ‘trial of treatment’ with close monitoring.

The Royal College of Physicians has also flagged up another key recommendation: to take into account the possible reasons for uncontrolled asthma, before starting or adjusting medicines for asthma in adults, young people and children. These may include:

  • alternative diagnoses;
  • lack of adherence;
  • suboptimal inhaler technique;
  • smoking (active or passive);
  • occupational exposures;
  • psychosocial factors;
  • seasonal or environmental factors.

Professor Mark Baker, director of the centre for guidelines at NICE, said: “We are recommending objective testing with spirometry and FeNO for most people with suspected asthma; a significant enhancement to current practice, which will take the NHS some time to implement, with additional infrastructure and training needed in primary care.

“New models of care, being developed locally, could offer the opportunity to implement these recommendations. This may involve establishing diagnostic hubs to make testing efficient and affordable. They will be able to draw on the positive experience of NICE’s primary care pilot sites, which trialled the use of FeNO.”

In his advice to patients, Dr Whittamore says: “NICE recognise that putting these guidelines into practice might take time, money and training – not everyone in England will have NICE standards of care immediately. If the NICE guidelines are not implemented in your area (you don't live in England, or your local NHS have not implemented it yet) don't worry. Alternative guidelines are not wrong, or unsafe, but NICE have tried to improve the accuracy of diagnosis and improve the cost-effectiveness of treatment of asthma.”

In its statement, the PCRS said it recognised “the importance of NICE’s incorporation of cost-effectiveness analysis, which is not addressed by BTS/SIGN.”

It has also announced it has produced guidance for primary care “based on an assessment of and taking account of the guidelines from BTS/SIGN and NICE. The briefing paper comments on the differences between the BTS/SIGN asthma guideline and the new NICE asthma guideline and makes recommendations about the most practical approach for primary care.

“In particular, the paper gives a detailed analysis of the two main areas where the NICE guideline recommends a different approach to established practice.”

The British Thoracic Society said it contributed to NICE’s stakeholder consultation on these guidelines, and met with NICE earlier this year “for a useful exchange of views.” In addition: “BTS will issue a clinical response to the NICE Guidelines shortly, which we hope will be helpful to people with asthma, their carers and healthcare professional.”

Links:
NICE announcement       
NICE guideline [NG80] ‘Asthma: diagnosis, monitoring and chronic asthma management’. November 2017              
NICE Quality standard [QS25] ‘Asthma’. Published February 2013, updated November 2017           
PCRS statement                  
Asthma UK Dr Andrew Whittamore blog post       
RCP statement  
BTS/SIGN British guideline on the management of asthma               

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