Section 1:

Key recommendations in the 2019 BTS/SIGN update

The 2019 update of the British guideline on the management of asthma includes a complete revision of the section on monitoring asthma, including new information on predicting future risk of asthma attacks, and updates to the sections on pharmacological management of asthma, supported self-management, non-pharmacological management, and management of acute asthma in adults and children.1

BTS, SIGN and NICE announced in July 2019 that future UK-wide guidance for the diagnosis and management of chronic asthma in adults, young people and children will be produced jointly by the three organisations.1

What’s new?
Diagnosis

BTS/SIGN states that diagnostic tests influence the probability of asthma but do not prove a diagnosis. They are usually performed at a single point in time whereas asthma status is variable. Objective tests performed when a patient is asymptomatic may produce a ‘false negative’ result.2

Compare the results of diagnostic tests taken while a patient is asymptomatic with those undertaken when a patient is symptomatic to detect variation over time.2
Objective tests used to support a possible diagnosis of asthma include spirometry and bronchodilator reversibility, peak expiratory flow (PEF), and fractional exhaled nitric oxide (FeNO).2

Carry out quality-assured spirometry using the lower limit of normal to demonstrate airway obstruction, provide a baseline for assessing response to initiation of treatment and exclude alternative diagnoses.2

  • Obstructive spirometry with positive bronchodilator reversibility increases the probability of asthma2
  • Normal spirometry in an asymptomatic patient does not rule out a diagnosis of asthma2

A positive FeNO test provides supportive but not conclusive evidence for an asthma diagnosis. FeNO levels may be increased in patients with allergic rhinitis or a cold, men, and tall people, and by the consumption of dietary nitrates, but lower in children, and reduced in cigarette smokers or by inhaled or oral steroids.2 Referral for challenge tests should be considered for patients with no evidence of airflow obstruction on initial assessment but for whom asthma remains a possibility.2

Diagnosis is based on the recognition of a characteristic pattern of respiratory symptoms and signs, the absence of any alternative explanation for symptoms and signs, and supported by objective tests.2

Undertake a structured clinical assessment, to include:2

  • History, ideally supported by variable PEF when symptomatic and asymptomatic;
  • Symptoms
  • Recorded observation of wheeze
  • Personal/family history of other atopic conditions;
  • No symptoms, signs or clinical history to suggest alternative diagnoses

In patients with a high probability of asthma, record as having suspected asthma and commence a carefully monitored initiation of treatment (typically six weeks of inhaled corticosteroids [ICS]). Assess response with a validated symptom questionnaire e.g. Asthma Control Questionnaire or Asthma Control Test, ideally supported by lung function tests. If symptomatic and objective response is good, confirm the diagnosis of asthma. If response is poor or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses.2

Monitoring

Assess risk of future asthma attacks at every asthma review (at least annually) by asking about history of previous attacks, objectively assessing current asthma control and reviewing reliever use.2

Non-pharmacological management

People with asthma and parents of children with asthma should be advised about the dangers of smoking and second-hand tobacco smoke exposure, and be offered support to stop smoking. Other measures include diet and exercise for overweight and obese patients, and breathing exercise programmes for adults.2

Pharmacological management

All adults and children with a diagnosis of asthma should be prescribed a short acting bronchodilator to relieve symptoms. For those with infrequent, short-lived wheeze, occasional use of reliever therapy may be the only treatment needed. Inhaled short-acting β2 agonists (SABA) are the drugs of choice, as they work faster and have fewer side effects than the alternatives.2

Good asthma control is associated with little or no need for SABA, which should only be used as required for the relief of symptoms.2

Over-reliance on SABA can cause tolerance and rebound effects.3

Anyone prescribed more than one SABA inhaler device a month should be identified and their asthma should be assessed urgently, and steps taken to improve asthma control if this is poor.2

Preventer therapy

Adults and children over 5 years using inhaled SABA three times a week or more, or who is symptomatic more than three times a week, or waking one night a week because of asthma symptoms, should be prescribed an inhaled corticosteroid (ICS). ICS should be considered for adults and children 5 –12 who have had an acute attack requiring oral corticosteroids in the previous 2 years. ICS is the recommended prevention drug for adults and children for achieving overall treatment goals.2 The first choice as add-on therapy to ICS in adults is an inhaled long-acting β2 agonist (LABA), which should be considered before increasing the dose of ICS.2 In children aged 5 and over, an inhaled LABA or leukotriene receptor antagonist can be considered as initial add-on therapy.2 Where patients require an ICS and a LABA, a combination inhaler is recommended to ensure that the LABA is not taken without the ICS and to improve adherence.2

MART

The use of a single combination inhaler for Maintenance And Reliever Therapy (MART) is an alternative approach to the introduction of a fixed-dose twice-daily combination inhaler which might suit some patients. MART combines rapid onset of reliever effect with formoterol with ICS, and as the need for a reliever increases, the dose of preventer is also increased. Patients taking rescue doses of their combination inhaler once a day or more on a regular basis should have their treatment reviewed.2
Not all combination products are licensed as MART. The appropriate combination inhaler should be prescribed by brand name.2

Please note that not all ICS+formoterol preparations are licensed for MART – check the summary of product characteristics for the individual product.2

Additional controller therapies

If asthma control remains suboptimal after addition of a LABA, then:2

  • Increase the dose of ICS from low dose to medium dose in adults or from very low dose to low dose in children (5–12 years).
  • Or consider adding a leukotriene receptor antagonist (LTRA)

Before initiating a new drug therapy, practitioners should check:2

  • Adherence with existing therapies
  • Inhaler technique
  • Eliminate trigger factors

All patients whose asthma is not adequately controlled on recommended initial or additional controller therapies should be referred for specialist care (Figure 1).2

The treatment algorithm for adults is shown in Figure 1, and the algorithm for paediatric asthma is shown in Figure 2.

FIGURE 1. BTS/SIGN TREATMENT ALGORITHM FOR ADULTS WITH ASTHMA

Adapted from BTS/SIGN British Guideline on the management of asthma, 2019

FIGURE 2. BTS/SIGN TREATMENT ALGORITHM FOR CHILDREN WITH ASTHMA

Adapted from BTS/SIGN British Guideline on the management of asthma, 2019

Inhaler devices

Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique.2 Avoid generic prescribing which may result in patients being given an unfamiliar device which they are not able to use properly.2

  • In children aged 5 – 12, a pMDI and spacer is the preferred option for both ICS and reliever, and is as effective as any other hand-held inhaler.2
  • In adults, a pMDI ± spacer is as effective as any other hand-held inhaler but patients may prefer some types of DPI.2
  • Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using the same type of device to deliver both preventer and relieved treatments may improve outcomes.2

Supported self-management

All people with asthma (and/or their parents or carers) should be offered self-management education, which should include a written personalised asthma action plan (PAAP), and be supported by regular professional review.2

Increasing inhaled corticosteroids to abort an asthma attack

Regular daily use of preventer medication is the best means of avoiding asthma attacks and the need for increased (rescue) doses of ICS. PAAPs typically include advice to increase the dose of ICS at the start of an asthma attack in an attempt to abort the attack.2
In PAAPs for adults, consider advising quadrupling ICS at the onset of an asthma attack and for up to 14 days to reduce the need for oral corticosteroids.2

Job code: UK/RES-19014b DOP: March 2020

References

  1. Scottish Intercollegiate Guidelines Network. Introduction to the British Guideline on the management of asthma; July 2019. https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma.html [Accessed March 2020].
  2. British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) British Guideline on the Management of Asthma; 24 July 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed March 2020].
  3. Valero A, Olaguibel J, Delgado J. Dilemmas and new paradigms in asthma management. J Investig Allergol Clin Immunol 2019;29(1):15-23.