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More inWhite Papers  

a man asthma inhaler imageDecember 1 2017

NICE has published new guidelines on asthma addressing diagnosis, monitoring and the management of chronic asthma.

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, that of taking 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.”

The Primary Care Respiratory Society UK (PCRS) said it was “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.”

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

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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