NICE Guidelines on Chronic asthma management

Nice has released its Guidelines on Asthma: diagnosis, monitoring, and chronic asthma management.The Guidelines aim to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks however they do not cover managing severe asthma or acute asthma attacks.

Principles of pharmacological treatment

Take into account the possible reasons for uncontrolled asthma, before starting or adjusting medicines for asthma in adults, young people, and children. These may include:

• alternative diagnoses


• lack of adherence


• suboptimal inhaler technique


• smoking (active or passive)


• occupational exposures


• psychosocial factors


• seasonal or environmental factors


• After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks (see recommendations on monitoring asthma control)


• If inhaled corticosteroid (ICS) maintenance therapy is needed, offer regular daily ICS rather than intermittent or ‘when required’ ICS therapy


• Adjust the dose of ICS maintenance therapy over time, aiming for the lowest dose required for effective asthma control

Ensure that a person with asthma can use their inhaler device:

• at any asthma review, either routine or unscheduled


• whenever a new type of device is supplied


• Pharmacological treatment pathway for adults (aged 17 years and over)


• This section is for people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance

Pharmacological treatment pathway for adults (aged 17 years and over)

This section is for people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance

• Offer a short-acting beta2 agonist (SABA) as reliever therapy to adults (aged 17 years and over) with newly diagnosed asthma


• For adults (aged 17 years and over) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone

Offer a low dose of an ICS as the first-line maintenance therapy for adults (aged 17 years and over) with:

• symptoms at the presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or


• asthma that is uncontrolled with a SABA alone


• If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks

If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:

• discuss with the person whether or not to continue LTRA treatment


• take into account the degree of response to LTRA treatment


• If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person’s ICS and LABA maintenance therapy to a MARTregimen with a low maintenance ICS dose


• If asthma is uncontrolled in adults (aged 17 years and over) on a MART regimen with a low maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy)

If asthma is uncontrolled in adults (aged 17 years and over) on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:

• increasing the ICS to a high maintenance dose (this should only be offered as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or


• a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) or


• seeking advice from a healthcare professional with expertise in asthma

Pharmacological treatment pathway for children and young people aged 5 to 16 years

This section is for children and young people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children and young people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow the guidance

• Offer a SABA as reliever therapy to children and young people (aged 5 to 16 years) with newly diagnosed asthma


• For children and young people (aged 5 to 16 years) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone

Offer a paediatric low dose of an ICS as the first-line maintenance therapy for children and young people (aged 5 to 16) with:

• symptoms at the presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or


• asthma that is uncontrolled with a SABA alone


• If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS as maintenance therapy, consider an LTRA*in addition to the ICS and review the response to treatment in 4 to 8 weeks


• If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA†in combination with the ICS


• If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS and a LABA as maintenance therapy, consider changing their ICS and LABA maintenance therapy to a MARTregimen‡ with a paediatric low maintenance ICS dose. Ensure that the child or young person is able to understand and comply with the MART regimen


• If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a MART regimen‡with a paediatric low maintenance ICS dose, consider increasing the ICS to a paediatric moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy)

If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric moderate maintenance ICS dose with LABA (either as MART or a fixed-dose regimen), consider seeking advice from a healthcare professional with expertise in asthma and consider either:

• increasing the ICS dose to paediatric high maintenance dose (only as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or


• a trial of an additional drug (for example, theophylline)

Pharmacological treatment pathway for children under 5 years

• It can be difficult to confirm asthma diagnosis in young children, therefore these recommendations apply to children with suspected or confirmed asthma. Asthma diagnosis should be confirmed when the child is able to undergo objective tests (see diagnosing asthma in young children in Asthma diagnosis and monitoring)


• This section is for children under 5 years with newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance


• Offer a SABA as reliever therapy to children under 5 with suspected asthma. This should be used for symptom relief alongside all maintenance therapy

Consider an 8‑week trial of a paediatric moderate dose of an ICS in children under 5 years with:

• symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or


• suspected asthma that is uncontrolled with a SABA alone

After 8 weeks, stop ICS treatment and continue to monitor the child’s symptoms:

• if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely


• if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy


• if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS


• If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as maintenance therapy, consider an LTRAin addition to the ICS


• If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS and an LTRA as maintenance therapy, stop the LTRA and refer the child to a healthcare professional with expertise in asthma for further investigation and management

Adherence

• For guidance on managing non-adherence to medicines in people with asthma, see the NICE guideline on medicines adherence

Self-management

• Offer an asthma self-management programme, comprising a written personalised action plan and education, to adults, young people and children aged 5 and over with a diagnosis of asthma (and their families or carers if appropriate)


• Consider an asthma self-management programme, comprising a written personalised action plan and education, for the families or carers of children under 5 with suspected or confirmed asthma

Increasing ICS treatment within a self-management programme

Within a self-management programme, offer an increased dose of ICS for 7 days to adults (aged 17 and over) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly outline in the person’s asthma action plan how and when to do this, and what to do if symptoms do not improve. When increasing ICS treatment:

• consider quadrupling the regular ICS dose


• do not exceed the maximum licensed daily dose

Within a self-management programme, consider an increased dose of ICS for 7 days for children and young people (aged 5 to 16) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly outline in the person’s asthma action plan how and when to do this, and what to do if symptoms do not improve. When increasing ICS treatment:

• consider quadrupling the regular ICS dose


• do not exceed the maximum licensed daily dose

Decreasing maintenance therapy

• Consider decreasing maintenance therapy when a person’s asthma has been controlled with their current maintenance therapy for at least 3 months


• Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of decreasing maintenance therapy

When reducing maintenance therapy:

• stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person’s preference


• only consider stopping ICS treatment completely for people who are using low dose ICS alone as maintenance therapy and are symptom free

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  • Agree with the person (or their family or carer if appropriate) how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and a follow‑up with a healthcare professional
  
  
  • Review and update the person’s asthma action plan when decreasing maintenance therapy
  
  
  
  

Risk stratification

Consider using risk stratification to identify people with asthma who are at increased risk of poor outcomes, and use this information to optimise their care. Base risk stratification on factors such as non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care for asthma

Terms used in this guideline

Expiratory polyphonic wheeze

A wheeze is a continuous, whistling sound produced in the airways during breathing. It is caused by narrowing or obstruction in the airways. An expiratory polyphonic wheeze has multiple pitches and tones heard over different areas of the lung when the person breathes out

ICS doses

ICS doses and their pharmacological strengths vary across different formulations. In general, people with asthma should use the smallest doses of ICS that provide optimal control for their asthma, in order to reduce the risk of side effects.

The full guideline contains the tables used to categorize the evidence base into low, moderate and high doses. The tables can be used as a guide for dosage in clinical practice, but should not be interpreted as a definitive statement of the relative potencies of the different inhaled steroids.

For adults aged 17 years and over:

• less than or equal to 400 micrograms budesonide or equivalent would be considered a low dose


• more than 400 micrograms to 800 micrograms budesonide or equivalent would be considered a moderate dose


• more than 800 micrograms budesonide or equivalent would be considered a high dose

For children and young people aged 16 years and under:

• less than or equal to 200 micrograms budesonide or equivalent would be considered a paediatric low dose


• more than 200 micrograms to 400 micrograms budesonide or equivalent would be considered a paediatric moderate dose


• more than 400 micrograms budesonide or equivalent would be considered a paediatric high dose

MART

Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required. MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

The objective test to diagnose asthma

Tests carried out to help determine whether a person has asthma, the results of which are not based on the person’s symptoms, for example, tests to measure lung function or evidence of inflammation. There is no single objective test to diagnose asthma

Risk stratification

Risk stratification is a process of categorizing a population by their relative likelihood of experiencing certain outcomes. In the context of this guideline, risk stratification involves categorizing people with asthma by their relative likelihood of experiencing negative clinical outcomes (for example, severe exacerbations or hospitalizations). Factors including non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care can be used to guide risk stratification. Once the population is stratified, the delivery of care for the population can be targeted with the aim of improving the care of the strata with the highest risk

Suspected asthma

Suspected asthma describes a potential diagnosis of asthma based on symptoms and response to treatment that has not yet been confirmed with objective tests

Uncontrolled asthma

Uncontrolled asthma describes asthma that has an impact on a person’s lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person’s quality of life and may lead to a medical emergency. Questionnaires are available that can quantify this

This guideline uses the following pragmatic thresholds to define uncontrolled asthma:

• 3 or more days a week with symptoms or


• 3 or more days a week with required use of a SABA for symptomatic relief or


• 1 or more nights a week with awakening due to asthma

At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.

At the time of publication (November 2017), not all LABAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.

At the time of publication (November 2017), MART regimens did not have a UK marketing authorisation for use in children and young people (aged under 12 years) for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.

At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.