Section 3:

Implications for practice

The existence of two guidelines, which correspond in some areas but not in others, has led to confusion and uncertainty for healthcare professionals.1,2

The Primary Care Respiratory Society (PCRS) UK has produced consensus advice on how to deal with conflicting national guidelines.1

1. Diagnosis

PCRS supports the BTS/SIGN approach to diagnosis, which assesses the probability of asthma as high, intermediate or low and emphasises a structured clinical assessment as the first step. Objective tests, in patients old enough to perform them, need to be part of the diagnostic assessment and repeated over time to demonstrate convincingly variable airflow obstruction.2

2. Management

PCRS recommends promoting non-pharmacological approaches, regardless of what medication patients are on, addressing smoking, weight control, activity/exercise and promoting use of spacers to increase efficacy of MDIs. Before any change is made to medication if control is inadequate, check for and address common causes of poor control, including incorrect or additional, comorbid diagnosis; lack of adherence; number of SABAs vs ICS being used; inappropriate inhaler technique; smoking (active or passive); occupational exposures; psychosocial factors; seasonal or environmental factors.2

Prescriptions for inhalers should be written by their brand name and device. Writing the generic name or not specifying the device may result in a patient receiving an inhaler they have not been taught to use.2 PCRS supports the use of regular low dose ICS with SABA on an as-required basis as first line maintenance treatment for most adults.2 PCRS advocates close monitoring of SABA use to ensure no more than 12 a year, with a threshold for ‘poor control’ as low as 6 per year, or between 6 and 12.2

The decision to use LTRA or LABA as first add-on therapy should be made in discussion between the clinician and the patient as there is little to choose between them, and both offer some advantages. It is inappropriate to switch a patient whose symptoms are well controlled on current treatment.2

3. Monitoring

PCRS agrees that asthma control should be monitored at every review, using PEF/spirometry and validated questionnaires to assess control. Observe and give advice on inhaler technique at every consultation; when there is deterioration in control; when the device is changed; if the patient requests a check.2

4. Self-management

PCRS, in line with BTS/SIGN, recommends supporting the patient in self-managing their condition and promotes the use of a PAAP.2

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

References

  1. Keeley D, Baxter N. Conflicting guidelines cause confusion in primary care. BMJ 2018;360:k29.
  2. Primary Care Respiratory Society (PCRS) UK briefing document: Asthma guidelines; November 2017. https://www.pcrs-uk.org/resource/briefing-asthma-guidelines [Accessed March 2020].