Dr Hilary Pinnock explains how SIGN and the BTS have been able to react quickly to the latest evidence by electronically updating their guideline each year
Maintaining guidelines is a challenge. New evidence appears so frequently that guidelines may be out of date before they are published, and long before planned review dates.
The process of developing guidelines takes time: months, or even years, can elapse between the review of evidence and publication. To minimise this problem, Scottish Intercollegiate Guidelines Network (SIGN) methodology incorporates a further literature search before the guideline is finalised,1 but with a complex guideline such as the British guideline on the management of asthma there can still be more than a year’s delay before publication.2
Instead of relying on the traditional two- or three-yearly updates the British Thoracic Society (BTS) and SIGN are pioneering an asthma ‘living guideline’. Fast-developing sections of the guideline will be the subject of a rolling programme of appraisal and review, and the online version will be updated annually. Web-based dissemination allows the lead time to publication to be reduced, so the guideline is as up to date as possible.
The first annual update was published on the BTS and SIGN websites (www.brit-thoracic.org.uk and www.sign.ac.uk) in April 2004.The changes are clearly marked in the revised chapters (Figure 1, below).
|Figure 1: Extract from the updated guideline showing how the revisions are marked|
Recommendations have been updated in the chapters on pharmacological management, management of acute asthma, organisation and delivery of care, and patient education and self-management. New evidence has been added to the diagnosis and natural history, asthma in pregnancy, and concordance and compliance sections. The process for 2005 is already underway, with revisions planned for other chapters.
The asthma ‘living guideline’ was developed according to SIGN methodology.1 Evidence review groups appraised literature published between January 2001 and March 2003, grading their recommendations from A to D according to the strength of the evidence (Figure 2, below). This now familiar system can help busy clinicians to assess the significance of the advice, although it is important to appreciate that lower grade evidence may be of considerable clinical relevance: not all questions are best answered by the randomised controlled trials needed for grade A recommendations.
|Figure 2: Key to evidence statements and grades of recommendation|
Inhaled steroids in mild asthma
Inhaled steroids should be considered for patients with any of the following:
- Exacerbations of asthma in the last two years
- Using inhaled beta2 agonists three times a week or more
- Symptomatic three times a week or more, or waking one night a week.
(Grade B for those aged 5 years or over, good practice point for the under-fives)
The 2004 guideline update reiterates that inhaled steroids are the recommended preventer drugs for adults and children, but includes further advice on the importance of considering inhaled steroid treatment in patients with milder asthma. This is based on two randomised controlled trials which showed that low dose inhaled steroids substantially reduced the risk of an exacerbation and symptoms in patients with mild persistent asthma.3,4
The START study 3 recruited adults and children (aged 5-65 years) with a recent diagnosis of asthma who had symptoms at least once a week but not more than daily. Despite this mild disease, 198/3568 (5.5%) of the placebo group required a course of oral steroids over the 3-year study period; 24 of the exacerbations were described as life-threatening.
Budesonide 400 mcg daily (200 mcg in children aged 5-11 years) reduced the number of oral steroid courses to 117/3597 (3.2%). Only nine of the exacerbations were life-threatening. Similar benefits were demonstrated in the OPTIMA study.4 Budesonide 200 mcg daily halved the number of ‘poorly controlled days’ in adults with mild asthma who were previously steroid naive. In both studies the drug was delivered by Turbohaler.
The low doses used in these studies emphasise the importance of titrating the dose of inhaled steroid to the lowest that prevents symptoms.
The OPTIMA study also supports the strategy of adding long-acting beta2 agonists to low doses of inhaled steroids to control symptoms in patients who are symptomatic on inhaled steroids.4 The recommendation in the 2003 guideline that there should be a trial of other treatments before increasing the inhaled steroid dose above 800 mcg per day in adults and 400 mcg per day in children is thus reinforced.
Asthma action plans
Patients with asthma should be offered self-management education that should focus on individual needs, and be reinforced by a written action plan. (Grade A)
The first Guidelines for the management of asthma in adults,5,6 published in 1990, stated that "as far as possible the patient should be trained to manage their own treatment rather than consult their doctors before making changes”. This concept continues to underpin the current guideline.
Additional studies undertaken in a range of clinical contexts including primary care 7 provide further support for the recommendation that self-management education should be offered to all patients with asthma, reinforced by written asthma action plans. The action plans used in the studies vary in their content and the way in which the programme is delivered, but key features include:
- Structured education, reinforced with written personal action plans, although the duration, intensity and format for delivery may vary
- Specific advice about recognising loss of asthma control, although this may be assessed by symptoms or peak flow or both
- Action to take if asthma deteriorates, including seeking emergency help, commencing oral steroids (which may include provision of an emergency course of steroid tablets) and recommencing or temporarily increasing inhaled steroids, as appropriate to clinical severity.
The 2004 guideline update recognises that the approach to self-management education should vary to meet the needs of diverse populations. For instance, teenagers may respond better to innovative, computer-based programmes,8 traditional action plans do not meet the needs of pre-school children many of whom have viral induced wheeze,9 and cultural considerations will influence programmes for ethnic groups.
The greatest benefits are demonstrated in those with the most severe disease. One group in whom self-management education is particularly important is those who have recently been admitted to hospital.10 The updated guideline therefore recommends that inpatients should be given an action plan before discharge. Clinicians should check during primary care asthma reviews that these high-risk patients have been given an action plan and that they understand it.
In primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management. (Grade B)
This recommendation for ensuring regular review of people with asthma is of particular relevance to primary care as it is reflected in the targets of the quality and outcomes framework of the new GMS contract.11
People with asthma are often reluctant to attend asthma clinics, so recent evidence that telephone consultations may be equally effective is welcome.
Health professionals who provide asthma care should have heightened awareness of the complex needs of ethnic minorities, socially disadvantaged groups, and those with communication difficulties. (Grade D)
The special needs of people in the minority groups must be recognised, but the grade D recommendation reflects the paucity of evidence on how best to support and help them. There is also little or no evidence regarding the elderly, who are often specifically excluded from studies in order to avoid the problems of comorbidity.
The development of a guideline, even when regularly updated, is only the beginning. Web-based dissemination, including educational resources, was used successfully to support the publication of the 2003 British guideline on the management of asthma.12 The living guideline programme will provide regular updates on the BTS and SIGN websites. However, clinical benefit for the five million people with asthma in the UK will only become a reality if the guidelines are accessed, locally considered and implemented.
- Scottish Intercollegiate Guidelines Network. SIGN 50. A guideline developers’ handbook. Edinburgh: SIGN, 2001.
- The British Thoracic Society/Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. Thorax 2003; 58 (S1): i1-i94.
- Pauwels RA,Pederen S, Busse WW et al on behalf of the START Investigators Group. Early intervention with budesonide in mild persistent asthma : a randomised, double blind trial. Lancet 2003; 361: 1071-6.
- O’Byrne PM, Barnes PJ, Rodriguez-Roisin R et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med 2001; 164: 1392-7.
- Guidelines for the management of asthma in adults. 1. Chronic persistent asthma. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Brit Med J 1990; 301: 651-3.
- Guidelines for the management of asthma in adults. 2. Acute severe asthma. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King’s Fund Centre, National Asthma Campaign. Brit Med J 1990; 301: 797-800.
- Thoonen BPA, Schermer TRJ, van den Boom G et al. Self-management of asthma in general practice, asthma control and quality of life: a randomised controlled trial. Thorax 2003; 58: 30-6.
- van Es SM, Nagelkerke AF, Colland VT et al. An intervention programme using the ASE-model aimed at enhancing adherence in adolescents with asthma. Patient Educ Couns 2001; 44: 193- 203.
- Stevens CA, Wesseldine LJ, Couriel JM et al. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Thorax 2002; 57: 39-44.
- Osman L,Calder C,Godden D et al.A randomised trial of self-management planning for adult patients admitted to hospital with acute asthma. Thorax 2002; 57: 869-74.
- Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk
- Dennis SM, Edwards S, Partridge MR et al. The dissemination of the British Guideline on the Management of Asthma 2003. (Respir Med: in press)