BTS/SIGN publishes asthma guideline update

BTS/SIGN has published an updated guideline on the management of asthma.  

Key areas that have been updated include: diagnosis, monitoring, supported self-management, non-pharmacological interventions, pharmacological management, inhaler devices, management of acute asthma, occupational asthma and provision of information.

Changes welcomed by PCRS are:

• An announcement that future guidance for the diagnosis and management of chronic asthma will be jointly produced by BTS, SIGN and NICE.  This will end confusion caused by conflicting guidance and is something PCRS has campaigned for.
• A recognition that achieving an accurate diagnosis may take time and may require the comparison of repeated measurements over time including while the patient is asymptomatic as well as when they are symptomatic.
• Spirometry is most helpful in cases when a person has an intermediate probability of asthma.  This should help inform commissioners who may be working with limited resources or have a need to prioritise the need for more specialist tests outside standard general practice diagnostic tests.
• FeNO testing should be used for diagnosis where there is an intermediate probability of asthma.  Routine use of FeNO testing in adults and children is not recommended except in specialist asthma clinics. The available evidence was inconsistent on how effective the test was in delivering different positive outcomes indicating better asthma control
• High SABA use is recognised as a risk factor for future attacks under ‘moderately increased risk’ – in adults as well as children.
• New guidance for commissioners on the importance of providing appropriate adequate training for staff delivering care.
• A greater emphasis on the need to treat tobacco dependence.
• An emphasis on the assessment of increased risk for future asthma attacks and the inclusion of a history of previous asthma attacks, poor current control and overuse of reliever medication as highlighted by the Asthma Right Care initiative. However PCRS finds BTS/SIGN cautious in its recommendations on the definition of an appropriate number of SABA inhalers a year.

Areas of concern are:

• The presentation of recommended inhaled medications for children. The guideline categorises medication into ‘very low dose’ ‘low dose’ and ‘medium dose’. This approach means that, the ‘medium dose’ could potentially be misinterpreted by a healthcare professional because it would be considered to be a high dose for a paediatric population.
• A recommendation that inhalers with a lower carbon footprint - such as dry powder inhalers (DPIs) - should be used when they are likely to be equally effective as metered dosed inhalers (MDIs) which have a higher global warming potential.  PCRS supports measures to reduce potential harm to the environment from inhaler use. However, we warn against any ‘blanket switching’ from MDIs to DPIs and encourage any decisions about inhaler choice to be made on an individual basis between clinicians and patients.

Carol Stonham PCRS Chair Elect says: “This update recognises the limitations of a single point in time testing and the importance of looking at symptoms and testing over time, comparing periods when the person is asymptomatic with when symptoms are present.

“There is much emphasis on assessing future risk with indicators for what increases risk – previous attacks, poor control and excessive SABA use.

“Treatment recommendations have not changed. LABA remains the first add on to ICS if there is poor control. This remains in conflict with the NICE 2017 asthma guideline.

“BTS/SIGN re-emphasises the importance of a personalised asthma action plan but the wording now stresses the importance of patient education with the action plan. There is a welcome acknowledgement that commissioners have a responsibility to ensure staff are trained and motivated to deliver asthma care.”

Read the PCRS briefing paper setting out our position on the recommendations of this update.