PCRS publishes pragmatic view of conflicting asthma guidelines
A new PCRS consensus based article offers clarity on the role of leukotriene receptor antagonists (LTRAs) as a first line add-on treatment in asthma and other controversial issues in asthma diagnosis and management.
The guidance has been developed by a multi-disciplinary team of health professionals with expertise in primary care respiratory medicine to provide clarity on aspects of diagnosis, management and monitoring of asthma that are confusing because of differences between the current national guidelines.
The choice of initial add-on treatment to low-dose inhaled corticosteroids (ICS) is a contentious issue. This is because the NICE guideline on asthma (published in 2017) considers an economic evaluation in addition to the clinical evidence whilst the BTS/SIGN guidance (updated in 2019) bases its recommendations solely on a critical appraisal of the literature. As a result, NICE recommends LTRAs as first line add-on therapy while BTS/SIGN recommends long acting beta agonists (LABA).
PCRS supports the value-based approach which NICE takes in recommending LTRAs. It considers that the marginal superiority of LABA in reducing exacerbations is outweighed by its greater cost. However, the PCRS guidance stresses that the decision should be made by the clinician after a discussion with the patient since both LTRA and LABA are options.
Another controversial issue on which NICE and BTS/SIGN make different recommendations is the use of the FeNO test in diagnosing asthma in primary care. The PCRS expert group recommends using FeNO as an optional investigation to test for eosinophilic inflammation in individuals where diagnostic uncertainty remains. But routine use of FeNO testing in adults and children is not recommended except in specialist respiratory clinics.
The article also examines the NICE and BTS/SIGN recommendations for diagnosing asthma and recommends a diagnostic strategy based on repeated clinical assessments, supported by objective clinical tests (including peak expiratory flow monitoring) and sensitively using trials of initiating and discontinuing therapy.
The article has been written by Dr Luke Daines, GP and Academic Clinical Fellow, University of Edinburgh, together with GP colleagues Noel Baxter, Kevin Gruffydd Jones, Steve Holmes and Duncan Keeley, nurse colleagues Val Gerrard and Carol Stonham and pharmacist Deborah Leese.
Luke says: “This article addresses the conflicting recommendations arising from the most recent versions of NICE and BTS/SIGN asthma guidelines. We sought to provide a pragmatic consensus, which is easy to digest and practical for clinicians in primary care.