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holmes steve

Guest Editor—Dr Steve Holmes

GP, Park Medical Practice, Shepton Mallet 

Since the latest update to the BTS/SIGN British guideline on the management of asthmawas issued in 2016, new guidance on the diagnosis and management of asthma was published by NICE in 2017. This email considers what the guidelines recommend on the management of asthma and provides advice on how to implement the recommendations in primary care.

The well established British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) guideline on the management of asthma was updated in 20161 and the NICE guidance on the diagnosis, monitoring, and management of asthma was published in 2017.2

The previous email in this series looked at the recommendations on diagnosing asthma, and this email will consider the advice on the management of asthma from the BTS/SIGN and NICE guidelines.

What are the similarities between the guidelines?

Inhaled corticosteroids

The BTS/SIGN and NICE guidance highlight that asthma is an inflammatory condition and the fundamental core treatment for most cases of asthma, excluding mild intermittent asthma, is an inhaled corticosteroid (ICS) .1,2

Both sets of guidelines suggest that ICS should be considered for people with asthma-related features such as:1,2

  • having had an asthma attack in the last 2 years
  • using an inhaled short-acting beta2-agonist (SABA) three times a week or more
  • symptomatic three times a week or more
  • waking one night a week due to asthma symptoms.

Response to treatment

The NICE and BTS/SIGN guidelines recommend the use of validated symptom questionnaires and objective measurement of lung function to measure response to treatment at a 4–8 week interval.1,2

Both guidelines also emphasise the importance of monitoring asthma control and adherence to treatment at every review, and the importance of checking inhaler technique carefully.1,2 Personalised asthma action plans are important for people to know what to do if they have severe symptoms.1,2

Finally, both NICE and BTS/SIGN highlight the importance of stepping down treatment, although the best way to do this is not made clear in either guideline (probably because of a lack of robust evidence).1,2

SABA reliever therapy

Both guidelines suggest that patients with newly diagnosed asthma should be offered a SABA as reliever therapy and suggest that asthma with infrequent, short-lived wheeze can be considered for treatment with SABA reliever therapy alone.1,2 In my experience, however, this is a rare situation; in practice, most people are using far more than the single SABA or less per year that would suggest that the condition is indeed mild and intermittent.

Reviewing medication

The NICE guideline advises reviewing patients 4–8 weeks after starting or adjusting medication, while BTS/SIGN suggests doing this at around 6 weeks.1,2

What are the differences between the guidelines?

Next step after ICS

The advice on the next treatment step after ICS varies between the guidelines. The BTS/SIGN guideline suggests adding a long-acting beta2 -agonist (LABA) and reviewing before modifying treatment further (and if required stopping the LABA if not effective)1—this has been clinical practice for more than 10 years.

NICE suggests offering a trial of a leukotriene receptor antagonist (LTRA) in addition to the ICS. This is a carefully considered position linked to the cost-effectiveness of LTRAs, some patients’ preference for oral therapy, and the research—much of which is summarised in a Cochrane review comparing LABA with LTRA therapy in addition to ICS in asthma.3

The Cochrane review comparing LABA with LTRA therapy found that in 18 randomised controlled trials including 7208 patients, most of which were in adults and adolescents, the risk of exacerbations was lower with a LABA than with an LTRA (13% compared with 11%), hence the number needed to treat for an additional beneficial outcome was 62.3 Use of a LABA also improved lung function to a greater extent, improved symptoms and quality of life, and required less rescue medication use, although these were modest improvements in the view of the authors. The LTRA appeared superior in preventing exercise-induced bronchospasm, although more patients preferred ICS/LABA and the withdrawal rate was lower in those using ICS/LABA.3 This would suggest that clinicians should have an informed discussion with patients around the available options and suggested treatments in the NICE and BTS/SIGN guidelines.

Maintenance and reliever therapy

Another difference between the two sets of guidelines is the importance that NICE places on maintenance and reliever therapy (MART). In the NICE guideline, MART with a low-dose ICS and LABA, with or without an LTRA, is a clear treatment step before moving on to a higher dose of ICS.2

Older clinicians may remember the days of doubling ICS when symptoms were worse (part of the rationale of MART therapy, but removed from the guidelines as a core part of asthma care more than 10 years ago). The NICE guideline suggests that an increased dose of ICS for 7 days for those who are using an ICS in a single inhaler is reasonable, recommending (as BTS/SIGN comments on) that the ICS should be quadrupled but should not exceed the maximum licensed dose.1,2

 

Learning points for asthma management

  • First-line treatment for all cases of asthma, excluding mild intermittent asthma, should be a low-dose ICS1
  • Validated symptom questionnaires and objective measurement of lung function should be used to measure response to treatment at a 4–8 week interval1,2
  • Personalised asthma action plans are important for people to know what to do if they have severe symptoms1,2
  • Patients with newly diagnosed asthma should be offered a SABA as reliever therapy1,2
  • If asthma symptoms persist after treatment with ICS, then the next step is to add either a LABA or an LTRA.1,2

References

  1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 153. BTS/SIGN, 2016. Available at: www.brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/

  2. NICE. Asthma: diagnosis, monitoring and chronic asthma management. NICE Guideline 80. NICE, 2017. Available at: www.nice.org.uk/NG80

  3. Chauhan B, Ducharme F. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev 2014; (1): CD003137.