The national guidance on asthma management produced in partnership by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) has been updated.
Health professionals have been advised to assess all asthma patients for their level of risk of having a future asthma attack and tailor their monitoring, treatment & care accordingly. A focus on asthma attack prevention is one of the key areas of advice in updated national guidance on the management of asthma produced by BTS and SIGN.
Every asthma review should involve an assessment (including various breathing tests and investigations) not only of current asthma control but of the key factors that put an individual at greatly increased risk of a future attack. These are: history of previous asthma attacks, poor current control of their asthma, and overuse of reliever medication.
Health professionals are also advised to be aware of factors that can ‘moderately’ or ‘slightly’ increase risk. In children: having an allergic disease as well as asthma, younger age, obesity and exposure to environmental tobacco smoke are markers of increased risk of future asthma attacks. In adults: older age, female gender, reduced lung function, obesity, smoking and depression are markers of a slightly increased risk of future asthma attacks.
The Guideline underlines the importance of asthma reviews taking place at least once a year where future asthma attack risk, current symptoms and treatment are all assessed – with growth also checked in children.
The guidance for monitoring asthma, based on all the latest evidence, does not recommend:
- Routine use of FeNO testing in adults or children except in specialist asthma clinics. The test involves measuring an individual’s fractional exhaled nitric oxide – a gas found in slightly higher levels in people with asthma. An increase may suggest some inflammation of the airways and supports but doesn’t prove, a diagnosis of asthma. The available evidence was inconsistent on how effective the test was in delivering different positive outcomes indicating better asthma control.
- Routine use of a sputum eosinophilia test – a specific test to assess ‘biomarkers’ of inflammation in a patient’s spit – in order to monitor asthma in adults or children.
The document also encourages NHS policymakers to address current inequalities in asthma outcomes by developing proactive plans to reach people with uncontrolled asthma, who may be vulnerable or from poorer backgrounds, and include support to quit smoking and reduce exposure to environmental tobacco smoke.
Other new or updated aspects of the guidance include the following:
- In asthma action plans for adults, health professionals are advised to consider quadrupling the level of the key inhaled preventer medication – inhaled corticosteroids (ICS) – at the onset of an asthma attack – and if necessary for up to 14 days after – in order to abort the attack and the need for ongoing oral steroids.
- Health professionals need to weigh up the benefit/risk ratio of the strategy in people already on high dose ICS – especially if they are experiencing frequent asthma attacks.
- If asthma symptoms are still problematic after use of ICS – the next ‘add on’ treatment recommended is an inhaled long-acting beta-agonist (LABA).
If this fails to gain control, then the guidance recommends increasing the dose of ICS from low to medium dose in adults or from very low dose to low dose in children (5–12 years). At this stage, health professionals can also consider a leukotriene receptor antagonist as an ‘add on’ treatment. This comes in tablet form and is sometimes called a ‘preventer tablet.’
- Health professionals should consider the option of combined maintenance and reliever therapy (MART) in adult patients who have a history of asthma attacks on medium dose ICS or ICS/LABA. MART is when patients are prescribed a combination inhaler to both prevent asthma symptoms and also relieve them when they arise. It may be easier for some patients as they don’t need to use an additional reliever inhaler for persistent symptoms.
- In a small proportion of patients, asthma is not adequately managed using standard controller therapies. New therapies are becoming available that particularly reduce the frequency of asthma attacks, but the choice and administration is complex and requires specialist input. Hence, the guideline now recommends that all patients whose asthma is not adequately controlled on recommended initial or additional controller therapies should be referred for specialist care.
Asthma inhalers and global warming
- Health professional prescribers, pharmacists and patients should be aware of the ‘significant differences’ in the global warming potential of different asthma inhalers which provide specific amounts of asthma drugs to the lungs (metered dosed inhalers (MDIs)). The Guideline recommends those with a lower carbon footprint – such as dry powder inhalers (DPIs) – should be used when they are likely to be equally effective.
- Patients should be encouraged to ask their pharmacy if they can recycle their used asthma inhalers.
- Breathing exercise programmes, conducted by a physiotherapist or using audio-visual programmes, can be offered to adults with asthma as an addition to medication to help improve quality of life and reduce symptoms.
- Given exposure to environmental tobacco smoke is associated with worsening asthma symptoms in children – people with asthma and parents/carers of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure and offered support to quit.
Dr John White, British Thoracic Society member and Consultant Respiratory Physician, York NHS Foundation Trust, who co-chaired the group that delivered the updated BTS/SIGN Guideline, said:
“At the heart of the new guideline is a drive towards providing more tailored and personalised care to help people manage their asthma effectively and reduce acute illness from the condition. The advice on how to predict an individual’s future asthma attack risk will support the NHS to identify those most likely to face potentially life-threatening attacks and deliver specific strategies to prevent this.
“This important work will support the NHS Long Term Plan’s aim to reduce health inequalities and variations in care that occur across different communities and parts of the country.
“The Guideline also underlines previous messages that are pivotal to combatting asthma, for example, it is critical that all asthma patients have a personalised action plan and their symptoms, medication and inhaler technique are monitored on an appropriate basis.
“We do hope that the Guidelines will help a range of health & care professionals to work together with people with asthma to provide the best possible treatment and care.”