Dr Sinan Eccles discusses how the interim All Wales guideline offers pragmatic advice to primary care to help address conflicts in current guidance for asthma

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Dr Sinan Eccles

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Read this article to learn more about:

  • differences in the recommendations made by the two main UK asthma guidelines
  • the All Wales Adult asthma management and prescribing guideline recommendations on diagnosis and management of asthma
  • self-management, personalised asthma action plans, and responding to poor asthma control.

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The British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) have jointly produced a regularly updated guideline on asthma care since 2003, with the most recent update published in 2019.1 In 2017, NICE published a guideline on asthma diagnosis and management.2 The BTS/SIGN and NICE guidelines differ in scope and methodology, resulting in significant differences between their recommendations (see Box 1) despite largely drawing on the same evidence-base.3

The BTS/SIGN guidance is already embedded in clinical practice and remains current, but the conflicting NICE guideline created uncertainty about how asthma should now be diagnosed and managed, particularly in primary care. In addition, the Global Initiative for Asthma (GINA) report has attracted increased attention in recent years and contains yet further differences in its recommendations, particularly with regard to treatment of mild asthma and choice of reliever medication.4

Box 1: Key differences between existing asthma guidelines

BTS/SIGN 20191

  • Recommends LABA as next add-on maintenance therapy if asthma is uncontrolled on low-dose ICS
  • Broad scope including acute asthma, asthma in pregnancy, occupational asthma, and organisation of services
  • Guidance driven by clinical effectiveness.

NICE 20172

  • Recommends addition of an LTRA as next add-on maintenance therapy if asthma is uncontrolled on low-dose ICS (and review the response in 4–8 weeks)
  • Prominent role of FeNO in diagnosis
  • Recommends considering SABA reliever therapy alone for adults (aged 17 and over) with asthma who have infrequent, short-lived wheeze and normal lung function
  • Scope focused on diagnosis, monitoring, and chronic asthma management
  • Guidance driven by cost-effectiveness.

GINA 20204

  • SABA reliever therapy alone not recommended for asthma
  • Recommends as-needed low-dose ICS with formoterol (without daily maintenance therapy) for mild intermittent asthma
  • Recommends as-needed low-dose ICS with formoterol as preferred reliever therapy.

All Wales adult asthma guideline 20205

  • Gives pragmatic recommendations in light of conflicting existing guidelines
  • Recommends LABA as next add-on maintenance therapy if asthma is uncontrolled on low-dose ICS, followed by a trial of LTRA if control remains sub-optimal
  • Offers specific advice on how to quadruple ICS dose to abort an asthma exacerbation
  • Aligned with supplementary educational information for healthcare professionals and patient-facing material through the NHS WalesAsthmahub app.

BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network; LABA=long-acting beta2 -agonist; ICS=inhaled corticosteroid; LTRA=leukotriene receptor antagonist; FeNO=fractional exhaled nitric oxide; SABA=short-acting beta2 -agonist; GINA=Global Initiative for Asthma

In August 2020, the All Wales Medicines Strategy Group (AWMSG) endorsed and published the All Wales adult asthma management and prescribing guideline.5 This is interim guidance for NHS Wales and will be superseded by the jointly developed NICE/BTS/SIGN guideline when it is published. The guideline was developed by the Welsh Respiratory Health Implementation Group (RHIG) as part of their asthma workstream, and offers pragmatic advice to primary care in light of the conflicting existing guidance.

In addition to the guideline, supplementary educational information has been developed for healthcare professionals delivering asthma care and patient-facing material is available through the NHS Wales Asthmahub app. The multiplatform information is aligned to encourage a consistent approach to asthma care in Wales.

Diagnosis

Asthma is a clinical diagnosis based on tests of airway hyper-responsiveness and airway inflammation. The AWMSG guideline recommends objective testing for all patients with suspected asthma, preferably prior to commencing treatment for asthma. Spirometry with reversibility testing and a peak flow diary are both useful tests to demonstrate variable airflow obstruction consistent with asthma. Inhalers that have already been prescribed should be withheld prior to performing bronchodilator reversibility testing.5,6

Obstructive spirometry is defined as a forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of <0.7 or below the lower limit of normal. A diagnosis of asthma is supported by a change in FEV1 of >12% and >200 ml on reversibility testing. Reversibility testing can be performed by administration of short-acting beta2 -agonist (SABA) therapy at the time of testing or following a trial of inhaled or oral corticosteroids.

Chronic obstructive pulmonary disease (COPD) can also exhibit some reversibility, and asthma and COPD can coexist (asthma–COPD overlap). The clinical history can help differentiate between asthma and COPD, with a large reversibility response (>400 ml) or serial peak flow measurements showing 20% or greater diurnal or day-to-day variation strongly supporting the presence of asthma.5

The AWMSG guidance states that a raised fractional exhaled nitric oxide (FeNO) level is supportive but not diagnostic of asthma.5 Additionally, FeNO testing is not currently widely available in primary care in Wales—the RHIG has produced a consensus statement on the use of FeNO testing in adults in Wales, which is available online.7

General principles of management

A consistent theme across all asthma guidance is that treatment will only be effective if it is taken, and taken correctly. To improve concordance, a discussion may be helpful to explain to the patient that:

  • asthma is usually an inflammatory condition
  • maintenance treatment will reduce inflammation and help prevent symptoms and exacerbations.

Inhaler choice should be tailored to the patient, who should be involved in the decision-making process. Inhalers are broadly categorised as dry powder inhalers (DPIs) and metered dose inhalers (MDIs). Whenever possible, DPI and MDI inhalers should not be mixed as part of an individual’s treatment regimen as they require radically different inhaler techniques. Detailed instructions on inhaler technique for specific devices can be found on the Right-Breathe app or the Asthma UK website.

The AWMSG guideline recommends that inhalers should usually be prescribed by brand to ensure the device provided is consistent.5 In accordance with the original guideline, brand names for individual inhalers and formulations have been included throughout this article.

Asthma management

Managing asthma involves maintaining control of symptoms and preventing exacerbations by adjusting doses and therapeutic options based on the patient’s use of reliever medication, symptomatic response, and whether exacerbations occur (see Figure 1).

All Wales adult asthma management and prescribing guideline management strategy summary

Figure 1: All Wales adult asthma management and prescribing guideline—management strategy summary

All Wales Medicines Strategy Group, Respiratory Health Implementation Group. All Wales adult asthma management and prescribing guidelines.  August 2020. Available at: awmsg.nhs.wales/files/guidelines-and-pils/all-wales-adult-asthma-management-and-prescribing-guidelines-pdf/

Mild asthma

Advice in the AWMSG guideline is aligned with GINA in stating that as-needed SABA therapy alone (without maintenance treatment) is inappropriate for asthma, based on the findings of the National Review of Asthma Deaths report.5,8 This is a point of contention between the existing guidelines, though the difference boils down to where the threshold lies for a diagnosis of asthma. Some individuals have rare episodes of ‘wheezy bronchitis’ associated with viral infections, with no symptoms or evidence of airflow obstruction, inflammation, or hyper-responsiveness outside of these episodes. Most clinicians would not label such a person as having asthma, and management with as-needed SABA in these cases would seem appropriate. Labelling such individuals as having asthma has broader implications and persuading them to take regular maintenance treatment is likely to be difficult.

The line between asthma and ‘infrequent, short-lived wheeze’ is not completely distinct, and clarifying the diagnosis when treatment has already been started can be difficult. As such, it is important to clearly record what clinical evidence and objective tests have formed the basis for a diagnosis of asthma.

There is recent evidence, acknowledged by the AWMSG guideline, supporting the use of ICS with a bronchodilator on an as-needed basis without daily maintenance treatment for people with mild asthma5,9,10 —a strategy supported by GINA, but not currently endorsed by BTS/SIGN or NICE. It is expected that most patients with mild asthma in Wales would continue to receive regular low-dose ICS treatment.

Stepping up therapy

If a patient is using their reliever medication more than twice a week, or is experiencing poor control as identified by the Royal College of Physicians ‘3 questions’ or a validated asthma symptom questionnaire (such as the Asthma Control Test), it is wise to consider a step up in management. Prior to stepping up treatment, a global assessment of factors potentially contributing to their poor asthma control should be undertaken, including a review of:5

  • inhaler technique
  • adherence to asthma medication:
    • explore barriers to concordance, using a non-judgemental approach
    • check the number of prescriptions for maintenance inhalers issued in the last 12 months compared with the number expected as a surrogate measure for concordance and a starting point for discussion with the patient
  • smoking status, referring the patient to stop smoking services if required
  • triggers (including occupational), and trigger avoidance
  • co-morbidities including obesity, rhinitis, and dysfunctional breathing.

Persistent asthma

Adding a long-acting beta2 -agonist (LABA) to low-dose ICS is recommended as the first step up for people whose asthma is not controlled with regular low-dose ICS, preferably using an ICS-LABA combination inhaler.5 LABA monotherapy (without concurrent ICS) is associated with an increased risk of asthma death and must not be prescribed.8 Regular low-dose ICS-LABA treatment can either be prescribed at a fixed dose with as-needed SABA reliever therapy, or as part of ‘maintenance and reliever therapy’ (MART) where the ICS-LABA combination inhaler acts as both the maintenance and reliever elements without the need for a SABA (see Table 1).5

Table 1: Licensed MART inhalers5
InhalerDoseMaximum daily dose

Fostair 100/6 Nexthaler or MDI (beclometasone dipropionate/formoterol)

1 puff twice daily plus as required

8 puffs

Duoresp Spiromax 160/4.5 (budesonide/formoterol)

1 puff twice daily plus as required, or 2 puffs twice daily plus as required

12 puffs

Fobumix Easyhaler 160/4.5 (budesonide/formoterol)

1 puff twice daily plus as required, or 2 puffs twice daily plus as required

12 puffs

Symbicort Turbohaler 200/6 (budesonide/formoterol)

1 puff twice daily plus as required, or 2 puffs twice daily plus as required

12 puffs

MART=maintenance and reliever therapy; MDI=metered dose inhaler

All Wales Medicines Strategy Group, Respiratory Health Implementation Group. All Wales adult asthma management and prescribing guidelines. August 2020. Available at: awmsg.nhs.wales/files/guidelines-and-pils/all-wales-adult-asthma-management-and-prescribing-guidelines-pdf/

Add-on therapy

For people whose asthma remains uncontrolled on regular low-dose ICS with LABA, a 6-week trial of montelukast 10 mg at night is recommended as the next step up in treatment. Montelukast may be particularly helpful in people with exercise-induced asthma or those with co-existent allergic rhinitis.5

Ongoing poor control

In people with ongoing poor control of their asthma, stepping up to a moderate dose of ICS in combination with a LABA is recommended. If control remains poor and other factors have been addressed, referral to secondary care should be considered, as asthma ‘phenotyping’ may be helpful to guide treatment. Other options include a trial of:

  • long-acting muscarinic antagonist (LAMA) inhaled therapy with Spiriva Respimat (tiotropium bromide) 2.5 mcg, two inhalations once daily alongside ICS-LABA treatment
  • increasing to high-dose ICS in combination with LABA.

Particularly at this stage, it is worth considering whether the diagnosis of asthma is accurate, and whether factors other than asthma could be driving symptoms.5

Stepping down therapy

Asthma control should be reassessed a maximum of 3 months after a change in treatment. The guideline recommends considering stepping down treatment if complete control has been achieved for at least 3 months. Where a reduction in ICS dose is considered, it should be reduced by no more than 50% each time.5

Self-management of asthma

Both NICE and BTS/SIGN guidelines highlight the importance of supported self-management.1,2 This includes a written personalised asthma action plan (PAAP), which should offer advice on recognising loss of asthma control based on symptoms and peak flow monitoring, and how to regain control (including when to start oral corticosteroids and seek emergency advice).5 Electronic asthma action plans are likely to become more popular in future; the NHS Wales Asthmahub app includes instructional and educational videos on asthma, and facilities to record peak flow readings and store a PAAP.

The NICE and BTS/SIGN guidelines also agree that, as part of a PAAP, it is reasonable to consider quadrupling the dose of ICS for a period if asthma control is deteriorating, based on evidence that this strategy can reduce the frequency of severe asthma attacks.1,2,11 There has been little practical advice on how to implement this recommendation. The AWMSG guidance recognises that this approach requires a motivated patient and will not be appropriate for all; for selected patients in whom this strategy is felt to be appropriate, those on ICS inhalers without LABA can simply quadruple their normal dose. For those on ICS-LABA combination inhalers, some patients will require a separate ICS inhaler in addition to their existing ICS-LABA inhaler to quadruple their ICS dose in order to avoid exceeding the maximum recommended dose of LABA (see Table 2). For some patients, proceeding directly to oral corticosteroids will be a better strategy as part of their PAAP.

Table 2: How to achieve a quadrupling in ICS as part of a PAAP in patients on a fixed dose ICS-LABA combination inhaler5
ICS-LABA inhalerMaintenance doseMethod of temporarily increasing in ICS[A]

Fostair 100/6 MDI (beclometasone diproprionate/formoterol)

1 puff twice daily

Increase maintenance dose to 4 puffs twice daily

2 puffs twice daily

Take maintenance dose and provide additional ICS inhaler: Clenil Modulite (beclometasone dipropionate) MDI 200 mcg, 6 puffs twice daily

Fostair 100/6 Nexthaler (beclometasone diproprionate/formoterol)

1 puff twice daily

Increase maintenance dose to 4 puffs twice daily

2 puffs twice daily

Take maintenance dose and provide additional ICS inhaler: beclometasone Easyhaler 200 mcg, 6 puffs twice daily

Symbicort 200/6 Turbohaler (budesonide/formoterol)

1 puff twice daily

Increase maintenance dose to 4 puffs twice daily

2 puffs twice daily

Take maintenance dose and provide additional ICS inhaler: budesonide Turbohaler 200 mcg, 6 puffs twice daily

Fobumix 160/4.5 (budesonide/formoterol)

1 puff twice daily

Increase maintenance dose to 4 puffs twice daily

2 puffs twice daily

Take maintenance dose and provide additional ICS inhaler: budesonide Easyhaler 200 mcg, 6 puffs twice daily

Duoresp Spiromax 160/4.5 (budesonide/formoterol)

1 puff twice daily

Increase maintenance dose to 4 puffs twice daily

2 puffs twice daily

Take maintenance dose and provide additional ICS inhaler: budesonide Turbohaler 200 mcg or Easyhaler 200 mcg, 6 puffs twice daily

Relvar Ellipta 92/22 (fluticasone furoate/vilanterol)

1 puff once daily

Take maintenance dose and provide additional ICS inhaler: fluticasone Accuhaler 250 mcg, 3 puffs twice daily

[A] It should be noted that the examples of additional ICS inhalers given for temporary increases in dose are good examples of prescribing choices but are not the only options available to achieve the increases described.

ICS=inhaled corticosteroid; PAAP=personalised asthma action plan; LABA=long-acting beta2 agonist; MDI=metered dose inhaler

All Wales Medicines Strategy Group, Respiratory Health Implementation Group. All Wales adult asthma management and prescribing guidelines. August 2020. Available at: awmsg.nhs.wales/files/guidelines-and-pils/all-wales-adult-asthma-management-and-prescribing-guidelines-pdf/

Summary

This article summarises some of the recommendations in the All Wales adult asthma management and prescribing guideline, including guidance on asthma diagnosis, stepping up and down of maintenance treatment, and supported self-management. The potential for smartphone apps to facilitate supported self-management is highlighted; this could be a simple change to implement for receptive patients. The guideline offers practical advice on how to navigate the differences between the existing BTS/SIGN and NICE guidelines, and should be straightforward to implement in primary care. The AWMSG guideline serves as interim guidance for NHS Wales and will be superseded by the BTS/SIGN and NICE collaborative guideline on asthma, which is in development at the time of writing (November 2020).

Dr Sinan Eccles

Consultant Respiratory Physician, Royal Glamorgan Hospital

Key points

  • The All Wales adult asthma management and prescribing guideline offers pragmatic advice to primary care clinicians in light of the conflicting BTS/SIGN and NICE guidelines
  • Asthma is a clinical diagnosis supported by tests of airway hyper-responsiveness and airway inflammation
  • Spirometry with reversibility testing and a peak flow diary are both useful tests to demonstrate variable airflow obstruction consistent with asthma
  • Asthma treatment is only effective if it is taken, and taken correctly
  • Where possible, do not mix DPIs and MDIs as part of an individual’s treatment regimen
  • Assess inhaler technique, adherence to medication, smoking status, triggers, and co-morbidities prior to stepping up treatment
  • If asthma is uncontrolled on regular low-dose ICS, add a LABA preferably as an ICS-LABA combination inhaler; consider doing so as part of a MART regimen
  • If asthma remains uncontrolled on low-dose ICS-LABA, give a 6-week trial of montelukast
  • Supported self-management of asthma can be facilitated by smartphone apps such as the NHS Wales Asthmahub app
  • For selected patients, quadrupling the dose of ICS when asthma control is deteriorating as part of a personalised asthma action plan can reduce the frequency of severe asthma attacks.

BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network; DPI=dry powder inhaler; MDI=metered dose inhaler; ICS=inhaled corticosteroid; LABA=long-acting beta2 -agonist; MART=maintenance and reliever therapy

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Recognise that:
    • although this guideline applies to Wales, its pragmatic review of the other asthma guidelines discussed could be useful for other regions of the UK
    • as well as disparity between guidelines, there is also disparity in the impact COVID-19 is having on asthma services:
  • Consider publishing a locally agreed ‘COVID-19 aware’ care pathway for asthma
    • be realistic about what services (e.g. FeNO testing) are currently available and feasible during the pandemic
    • consider developing local guidelines that are simple to implement and that minimise the need for face-to-face consultation during the pandemic
  • Extract the key messages from the national guidance (combined inhaled corticosteroid/LABA and step-up therapy) and publish in local formularies and on other local websites
  • Encourage further the use of PAAPs during the pandemic to empower and enable patients to self-monitor and intensify medication when access to services may be more difficult.

STP=sustainability and transformation partnership; ICS=integrated care system; LABA=long-acting beta2 -agonist; PAAP=personalised asthma action plan

Implementation actions for clinical pharmacists in general practice

written by Anna Prescott, Clinical Services Manager, Soar Beyond

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.

Asthma can be effectively managed by clinical pharmacists through the implementation of evidence-based management.

The poor outcomes associated with asthma, lack of patient understanding, and the disparities between national guidance offers an opportunity for pharmacists to facilitate quality improvement in asthma care. In fact, the PCN DES places an emphasis on the proactive management of patients with asthma through specialised clincs.[A]

  • Carry out an audit to identify key issues in the current management of asthma, including cause an effect analysis to identify areas for improvement, covering:
    • the proper use of asthma control tests
    • whether patients are on the correct therapy
    • inhaler technique and personalised asthma action plans.
  • Collaborate with the practice team to ensure consistency in care, especially if guideline differences are causing confusion
  • Set up specialised asthma clinics where competence and confidence allows, including pharmacist-led reviews that may include:
    • review of asthma control using spirometry or peak flow
    • observation of inhaler technique
    • review of symptoms
    • medicine advice including on adverse effects
    • adherence check
    • advice on stopping smoking where relevant
    • appropriate prescribing and deprescribing
    • ensuring patient understanding and issuing of personalised asthma action plans.
  • Empower patients to self-manage where appropriate.

Guidance and training for both quality improvement and asthma clinics are available for a range of clinical areas from Soar Beyond and their i2i network. If you are a pharmacist working in practice, join the i2i network for free where you can access training and implementation resources to support you in your role.

[A] NHS England and NHS Improvement. Network contract Directed Enhanced Service contract specification 2020/21—PCN requirements and entitlements. September 2020. Available at: https://www.england.nhs.uk/wp-content/uploads/2020/03/Network-Contract-DES-Specification-PCN-Requirements-and-Entitlements-2020-21-October-FINAL.pdf

PCN=Primary Care Network; DES=Directed Enhanced Service

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After reading this article, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

  1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 158, updated 2019. Available at: www.sign.ac.uk/media/1048/sign158.pdf
  2. NICE. Asthma: diagnosis, monitoring and chronic asthma management. NICE Guideline 80. NICE, 2017. Available at: www.nice.org.uk/ng80
  3. White J, Paton J, Niven R, Pinnock H on behalf of the British Thoracic Society. Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE. Thorax 2018; 73: 293–297.
  4. Global Initiative for Asthma. Global strategy for asthma management and preventionupdated 2020. GINA, 2020. Available at: ginasthma.org/gina-reports/
  5. All Wales Medicines Strategy Group, Respiratory Health Implementation Group. All Wales Adult asthma management and prescribing guidelines. August 2020. Available at: awmsg.nhs.wales/files/guidelines-and-pils/all-wales-adult-asthma-management-and-prescribing-guidelines-pdf/
  6. Graham B, Steenbruggen I, Miller M et al. Standardization of spirometry 2019 update—an official American Thoracic Society and European Respiratory Society technical statement. Am J Respir Crit Care Med 2019; 200: e70–e88.
  7. Respiratory Health Implementation Group. Consensus statement for FeNO testing in adults in Wales. 2019. Available at: clinicalscience.org.uk/assets/Consensus-statement-for-FeNO-testing-in-adults-in-Wales.pdf
  8. Royal College of Physicians: Why asthma still kills: the National Review of Asthma Deaths (NRAD). London: RCP, 2014. Available at: www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  9. Bateman E, Reddel H, O’Byrne P et al. As-needed budesonide–formoterol versus maintenance budesonide in mild asthma. N Engl J Med 2018; 378: 1877–1887.
  10. O’Byrne P, FitzGerald J, Bateman E et al. Inhaled combined budesonide–formoterol as needed in mild asthma. N Engl J Med 2018; 378: 1865–1876.
  11. McKeever T, Mortimer K, Wilson A et al. Quadrupling inhaled glucocorticoid dose to abort asthma exacerbations. N Engl J Med 2018; 378: 902–910.