Implementing the new joint NICE asthma guidelines

GP and respiratory expert Dr Andrew Whittamore outlines the key updates in new joint NICE/BTS/SIGN asthma guidelines and advises on how best to implement the changes

NICE has worked with BTS and SIGN to produce a unified guideline on asthma.¹ The guidance aims to modernise asthma management, in particular to support more accurate diagnosis and introduce more effective treatment regimens, to improve outcomes for the 5.4 million people in the UK with asthma.

This article will outline some of the key updates for GPs within the guideline and how to put them into practice.

Several recommendations will need time to filter through to the NHS. For example, funding mechanisms will need to catch up with these guidelines so that fractional exhaled nitric oxide (FeNO) testing and spirometry can be made uniformly available to patients. In addition, the current QOF rules on diagnosis are based on an older version of the guidelines.

Key updates in diagnosis

History is key

Although not a new concept, history is made more prominent in the updated guideline. With a solid basis for why we believe someone has asthma, we can improve the specificity of the diagnostic tests we then use to confirm or exclude a diagnosis.

Documenting a clear picture of respiratory symptoms, their triggers and any risk factors for developing asthma is essential because of the variable course of the condition and because we are potentially committing to a sequence of tests to confirm asthma.

Alternative causes of the symptoms should also be explored. Anyone for whom asthma is being considered must be read-coded as having Suspected Asthma, to support future decision making.

A single objective test may be enough for diagnosis

Because there is no perfect test with both a high specificity and high sensitivity for diagnosing asthma, previous guidelines (and thus QOF) have relied on history plus a combination of available tests to increase certainty. This guideline has employed two strategies for simplifying this.

Firstly, as above, it places a greater emphasis on ensuring a good clinical history is taken.

Secondly, it uses a sequential approach to testing, as summarised in Box 1 below and laid out in NICE/BTS/SIGN algorithms for objective diagnostic testing in adults and young people aged 16 and over, and in children aged 5 to 16.

By using a highly specific initial test with a high threshold for positivity (as with FeNO and eosinophil tests) we can be more certain that the initial positive test is correct.

Conversely, most asthma tests have low sensitivity, meaning they have a good chance of providing false-negative results. Therefore, in the event of a negative result we should move to the next test in sequence.

Testing for eosinophilic inflammation

For the majority of people with asthma, symptoms are linked to high levels of eosinophilic inflammation. To identify this, blood eosinophil levels and FeNO are useful. Where there is a positive history, these tests have high specificity at the recommended thresholds (FeNO ≥50ppb in adults, FeNO ≥35ppb in 5-16 year olds, eosinophils ≥upper laboratory threshold, often 0.5×10⁹/L).

FeNO is now recommended as the first line test for adults and children over 5 years, with blood eosinophil count an alternative option in adults. Because of the variable nature of asthma, these tests are more likely to be positive in someone with asthma when they are symptomatic. The guidelines therefore suggest performing these tests at acute presentations where asthma is suspected or as soon as possible after (see below).

Asthma is characterised by variable/reversible airflow obstruction

Where tests for inflammation do not confirm asthma in someone with suspected asthma, a test for airflow obstruction should be carried out. Spirometry with bronchodilator reversibility (BDR) is the preferred test here. Because of the variable nature of asthma, these tests are more likely to be positive in someone with asthma when they are symptomatic. The guidelines suggest performing these tests at acute presentations where asthma is suspected or as soon as possible after (see below).

Peak flow has a back-up role

Within the diagnosis section of the NICE/BTS/SIGN asthma guidelines there are two possible uses for peak flow. Firstly, where spirometry is not available or if there are likely to be delays in getting spirometry then a 2-week peak flow diary can be considered. Secondly, in the scenario where the patient is presenting acutely with symptoms suggestive of asthma then peak flow readings before and after bronchodilation can be performed to aid diagnosis.

Diagnosis needs to start during acute presentations

People presenting acutely with a suspected asthma component to their symptoms should be treated as if they have acute asthma. A history should be taken, and documented, to outline why asthma should be suspected, followed by objective tests such as FeNO, blood eosinophil count (adults only), BDR or pre- and post-bronchodilator peak flow readings as above.

All of these tests are more likely to produce a positive test when someone is symptomatic. If testing at this stage is not possible then they should be carried out when their acute symptoms are controlled but bearing in mind that any results when on treatment or when less symptomatic are less likely to be as positive. Primary care, as well as acute settings, will need to consider availability of suitable objective tests for patients presenting with suspected asthma.

Treatment updates

Patients diagnosed with asthma should no longer be prescribed SABA alone

There are clear data that unopposed or excessive use of short acting bronchodilator agonists (SABAs) increases risk of asthma attacks and death.² The new guidance makes it clear that no patient should be prescribed a SABA without also being prescribed a regular inhaled corticosteroid (ICS). There is also a shift away from SABA use in general.

Key updates to treatment recommendations are summarised in Box 2 below and outlined in the NICE/BTS/SIGN algorithms for treatment of people with asthma aged 12 and over and for treatment in children with asthma aged 5-11.

Formoterol is a LABA which works as rapidly as salbutamol and is as effective in treating acute symptoms. In a combination inhaler with an ICS, when used as a reliever inhaler, the ICS-formoterol relieves the acute symptoms while also addressing the underlying inflammation which causes the symptoms in the first place. This approach allows titration of the preventer medication in line with the variable nature of asthma. This reduces future symptoms and reduces risk especially compared to previous approaches which titrate SABA use and enables untreated inflammation to escalate.

When an inhaler containing ICS-formoterol is prescribed to relieve symptoms, this is known as Anti-Inflammatory Reliever therapy (AIR). When this inhaler is used for both maintenance and relief, this is known as maintenance and reliever therapy (MART). This guideline allows patients to self-titrate between AIR and MART. Most patients will require MART to treat underlying inflammation and keep on top of their symptoms. Patients with infrequent or seasonal symptoms may rotate between AIR and MART. This is a major culture change in treatment approach from previous guidelines and it is essential that everyone in health and care understand it (including community pharmacies and acute care providers such as 111 and 999 services).

There are many different types of inhaler with different drugs, doses and devices. This guideline supports the off-license use of an appropriately-dosed inhaler as long as the patient can use it correctly. This provides greater flexibility for moving patients to a SABA-free regime but does mean that prescribers, especially those signing prescriptions for non-prescribers are comfortable with inhaler choices and off-license prescribing.

As above, the overall evidence behind MART and AIR is that these regimes are safer and more effective than other regimes, and the guideline suggests that people with uncontrolled asthma should be switched. There are other possible benefits for AIR/MART such as: a simpler regime; requirement for fewer inhalers (cheaper); and lower greenhouse emissions. I would suggest offering well-controlled asthma patients on ICS/LABA with SABA to swap to AIR/MART at a routine review, explaining the clinical and non-clinical benefits.

Review and monitoring

Annual review is a minimum

People with asthma should have an asthma review at least annually if well-controlled and more often if poorly controlled. They should also be reviewed after every asthma exacerbation. This is crucial as an asthma exacerbation is a sign of a failure of the treatment plan, and is a marker for future exacerbations and risk of death. However, primary care will need updated systems and capacity to identify and review exacerbations from all acute settings.

Identifying poor control is important

A key theme within the updated guideline is that a lot of asthma care should happen outside of the annual review – for example, it recommends observing inhaler technique at every opportunity and that patients should always undergo post-exacerbation reviews. Note also the guidance recommends a review of asthma control and medication early in pregnancy and in the postnatal period.

Asthma control should be checked at every review. This means that all clinicians in contact with people with asthma need to be able to effectively perform all of these actions, not just those working in practice asthma clinics.

The check should include:

• Asthma Control Test, children’s Asthma Control Test or Asthma Control Questionnaire.
• Time off school or work.
• Number of courses oral steroids.
• Number of emergency presentations with chest symptoms.
• Reliever inhaler use include checking the prescribing record.
• Peak flow if this is part of someone’s asthma action plan. However, having a measure of someone’s peak flow when well can be a useful benchmark for acute episodes.

For adults with asthma, GPs should also now consider monitoring FeNO levels at their regular review, and before and after changing treatment (see below).

Uncontrolled asthma can include one or both of:

• any asthma exacerbation needing treatment with oral corticosteroids;
• frequent regular symptoms such as: needing a reliever inhaler 3 or more days per week, or; having 1 or more nights per week when asthma causes night-time waking.

Assessing inflammation is a key part of the monitoring process

In adults only, FeNO should now be considered within the annual review as well as before and after any change in therapy. A high FeNO level demonstrates untreated eosinophilic inflammation. This might be because of poor adherence to preventer medication, inadequate inhaler technique or a need for a higher dose of inhaled steroids.

If FeNO is not raised in someone who continues to have asthma-like symptoms despite treatment, consider alternative causes for those symptoms rather than simply increasing the inhaler dose.

FeNO and eosinophil levels should also be measured in anyone over 12 who is poorly controlled despite good adherence with a moderate-dose MART inhaler. Raised levels of either should trigger a referral to a specialist asthma service to consider specialist treatments such as biologics.

If neither are raised in anyone over 12 who is poorly controlled despite good adherence with a moderate-dose MART inhaler then a limited trial of montelukast and a LAMA should be tried. Where these fail to control symptoms then a referral to a specialist asthma service is indicated.

Self-management advice

Provide patient education

As well as a personalised written asthma action plan, adults, children and their carers should now be offered:

• Education about their asthma and how to self-manage their symptoms.
• Information about common triggers and how to address them including indoor and outdoor pollution.
• Smoking cessation advice and support.

Schools and health services should work together to provide in-school asthma self-management education programmes provided by appropriately trained personnel. Processes need to be developed to support both schools and the NHS to work closer together to support children with asthma.

Dr Andrew Whittamore is a GPSI in respiratory medicine in Hampshire

References

1. NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] 27 November 2024
2. Levy M, Beasley R, Bostock B et al. A simple and effective evidence-based approach to asthma management: ICS-formoterol reliever therapy. Br J Gen Pr 2024; 74(739):86-89

Resources and further reading

NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] Resources: Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline. 27 November 2024

Primary Care Respiratory Society UK. Are you ready for the new asthma guideline? 2024

Asthma and Lung UK. Resources for healthcare professionals

Asthma and Lung UK. Resources for patients