SECTION 2:

Key variations from the NICE guideline

The NICE guideline on the diagnosis, monitoring and management of chronic asthma, was published in 2017.1 It was decided that NICE should produce the guidance back in 2013, both to incorporate cost effectiveness analyses (which BTS/SIGN guidance does not include) and to address concerns about potential overdiagnosis, overtreatment and, therefore, wasted resources.2 Despite concerns raised during the consultation, the NICE guideline retained recommendations for spirometry and FeNO tests as objective tests to confirm a diagnosis of asthma,2 and unlike BTS/SIGN, NICE rejected the concept of trials of treatment as a diagnostic tool.2
Key differences in treatment approaches between BTS/SIGN and NICE are shown in Table 1 (adults) and Table 2 (children)

Table 1. APPROACHES TO TREATMENT IN ADULTS WITH ASTHMA

BTS/SIGN 20193 NICE NG80, 20171
Initial management in adults Regular low dose ICS + SABA as required SABA + low dose ICS if SABA does not control symptoms
If asthma is uncontrolled with initial management – adults Low dose ICS + LABA either as fixed dose or MART Continue ICS + trial of LTRA. Review response to treatment in 4–8 weeks
If asthma is still uncontrolled – adults Consider increasing ICS to medium dose or adding LTRA. If no response to LABA, consider stopping LABA

Refer patient for specialist care

Offer LABA + low dose ICS, review LTRA treatment in discussion with patient and taking account of degree of response

Offer to change ICS+LABA to MART
Consider increasing ICS dose to moderate – either continue MART or switch to fixed-dose ICS and LABA + SABA as reliever therapy (+/- LTRA)

Consider

  • Increasing ICS to high maintenance dose (only as part of fixed dose + SABA as reliever therapy), or
  • Trial of additional drug e.g. long acting muscarinic receptor antagonist (LAMA) or theophylline, or
  • Seeking advice from healthcare professional with expertise in asthma

Table 2. APPROACHES TO TREATMENT IN CHILDREN WITH ASTHMA

BTS/SIGN 20193 NICE NG80, 20171
Initial management in children* Monitored initiation of very low- (paediatric) dose to low-dose ICS + SABA SABA. Initiation of low- (paediatric) dose ICS only if the child has asthma symptoms >3 times a week, waking at night or uncontrolled with SABA alone
If asthma is uncontrolled with initial management – children* Regular very low- (paediatric) dose ICS + LABA or LTRA if using >3 doses SABA/week Consider LTRA + low- (paediatric) dose ICS
Review response to treatment in 4–8 weeks
If asthma still uncontrolled – children* Consider increasing ICS dose to low dose or in children ≥5, adding LTRA or LABA. If no response to LABA, consider stopping LABA

Refer child for specialist care

Consider stopping LTRA and starting LABA + ICS
Consider changing ICS+LABA to MART (paediatric low dose ICS)
Consider increasing ICS to paediatric moderate dose – either continue MART or switch to fixed-dose ICS and LABA + SABA as reliever therapy
Consider seeking advice from healthcare professional with expertise in asthma and increasing ICS dose to paediatric high dose or trial of additional drug, e.g. theophylline

*BTS/SIGN recommendations above cover children up to age 18. NICE defines children aged <5 years, or 5–16 years. NICE’s recommendations for children <5 are not included in this summary – see full guideline at https://www.nice.org.uk/guidance/ng80/

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

References

  1. NICE NG80. Asthma: diagnosis, monitoring and chronic asthma management; November 2017. https://www.nice.org.uk/guidance/ng80/ [Accessed March 2020].
  2. Keeley D, Baxter N. Conflicting guidelines cause confusion in primary care. BMJ 2018;360:k29.
  3. 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].