Asthma management- NICE guidance

Description and transcript

My name is Fernando Florido and I am a GP in the United Kingdom. In this video I have done a summary of the NICE guidance on asthma management. The full guideline also contains advice on asthma diagnosis and, if you are interested in this, please refer to the corresponding episodes on this channel. The NICE guideline “Asthma: diagnosis, monitoring and chronic asthma management” or NG80 was published on 29 November 2017 and it was last updated on 22 March 2021 

There is a Youtube version of this and other videos that you can access here: 

·      @nicegp : https://www.youtube.com/channel/UClrwFDI15W5uH3uRGuzoovw

Full NICE guideline on Asthma:  

·      Website: https://www.nice.org.uk/guidance/ng80 

·      Or download here: Asthma NG80.pdf 

Table of ICS and equivalent doses: 

·      Website: inhaled-corticosteroid-doses-pdf-4731528781 (nice.org.uk)

·      Download: https://1drv.ms/b/s!AiVFJ_Uoigq0lhdkbb2S-N9W_AUw?e=PndeXG

Guidance on how to minimise exposure to air pollution:

·      recommendations on vulnerable groups in the NICE guideline on air pollution: outdoor air quality and health 

·      recommendations on people with asthma, other respiratory conditions or cardiovascular conditions in the NICE guideline on indoor air quality at home 

Short explanation for the change in the recommendation on increasing ICS treatment within a self-management programme in children:

·      see the rationale and impact section on self-management .

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Transcript

Hello everyone and welcome. My name is Fernando Florido and I am a GP in the United Kingdom.

In today’s episode we are looking at a summary of the NICE guidance on asthma management. The full NICE guideline also contains advice on asthma diagnosis and, if you are interested in this, please refer to the corresponding episodes on this channel. 

Remember that there is also a Youtube version of these episodes so have a look in the description.

We will start by saying that we need to consider possible reasons for uncontrolled asthma, before starting or adjusting medicines including:

·      alternative diagnoses

·      lack of adherence

·      poor inhaler technique

·      smoking

·      and occupational exposures amongst others

By the way, we will define uncontrolled asthma as:

• 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.

Other pharmacological principles to follow are:

1.   That we will review the treatment after 4 to 8 weeks of initiation or change

2.   If needed, we will offer regular daily ICS rather than intermittent therapy

3.   And that we will adjust ICS doses aiming for the lowest dose required

The pharmacological treatment that is recommended in the guideline is for people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. So, no need to change people who are stable.

NICE has produced three pathways:

1.   recommendations for adults over the age of 17

2.   recommendations for children aged between 5 and 16 years of age

3.   recommendations for children under 5

But in fact, the recommendations for adults and children between the ages of 5 and 16 are very similar so, in order to avoid excessive repetition, I will amalgamate them together and simply point out the differences between them as and when appropriate.

And, even before we start, I need to point out the difference between ICS adult and paediatric doses. NICE makes recommendations in terms of low dose, moderate dose and high dose of ICS. But this means different things for adults and children.

For adults aged 17 and over:

• up to and including 400 mcg of budesonide or equivalent is a low dose
• more than 400 mcg and up to 800 mcg of budesonide or equivalent is a moderate dose
• more than 800 mcg budesonide or equivalent is a high dose.

However, for children and young people aged 16 and under the thresholds are half of the adults’. That is:

• up to and including 200 mcg budesonide or equivalent is a paediatric low dose
• more than 200 mcg and up to 400 mcg budesonide or equivalent is a paediatric moderate dose
• more than 400 mcg budesonide or equivalent is a paediatric high dose.

And remember that budesonide and beclomethasone have dose equivalence but the potency of fluticasone is roughly double that.

NICE has produced a table of various ICS showing their low, moderate, and high dose thresholds. Please have a look in the episode description if you are interested.

We also need to be aware that at the time of publication, the use of some medicines was off label in children, like the use of some LTRAs, LABAs and MART recommendations.

Asthma management follows a stepwise approach.

In adults and children aged 5 to 16:

1.   Firstly, we will just offer a short-acting beta2 agonist (SABA) as reliever therapy for infrequent, short-lived wheeze. 

2.   Then, if there are symptoms of uncontrolled asthma, we will offer a low dose of an ICS. Remember that uncontrolled asthma would be asthma-related symptoms 3 times a week or more, or causing waking at night.

3.   If asthma remains uncontrolled, we will offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review in 4 to 8 weeks. 

4.   Then, if symptoms persist, we will offer a long-acting beta2 agonist (LABA) in combination with the ICS, and we will consider stopping the LTRA treatment depending on the response.

5.   If an increase in treatment is still needed, we will offer to change the ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose.

 

Let us stop here for a second. What is MART? MART stands for Maintenance and reliever therapy and 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 combinations in which the LABA has a fast-acting component (for example, formoterol). Inhalers with salmeterol, for example, would not be suitable for this.

 

6.   If asthma is uncontrolled on a MART regimen with a low maintenance ICS dose, with or without an LTRA, we will increase 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). 

7.   And finally, if symptoms control remains poor, we will consider one of the following:

·      We will refer to an asthma specialist. And we will do this especially for children as we consider stepping up their treatment.

·      We can also increase the ICS to a high dose as part of a fixed-dose regimen, with a SABA used as a reliever therapy or

·      We could also start a trial of an additional drug (for example, theophylline) 

The pharmacological treatment pathway for children under 5 is slightly different.

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.

In terms of pharmacological treatment,

1.   First, we will offer a SABA as reliever therapy

2.   Then, we will consider an 8‑week trial of a paediatric moderate dose of an ICS in children under 5 with asthma-related symptoms 3 times a week or more, or causing waking at night

3.   After 8 weeks, we will stop the ICS treatment and:

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

·      if symptoms resolved but reoccurred beyond 4 weeks after stopping, we will repeat the 8‑week trial of a paediatric moderate dose of ICS. 

·      if symptoms resolved but then reoccurred within 4 weeks of stopping, we will restart the ICS at a paediatric low dose, not a moderate dose

4.   If the suspected asthma is uncontrolled on a paediatric low dose of ICS we will consider an LTRA in addition to the ICS. 

5.   If the suspected asthma remains uncontrolled on a paediatric low dose of ICS and an LTRA, we will stop the LTRA and refer to an asthma specialist

Now, there is a self-management section that we will address now.

And it says that all patients over the age of 5 should have a written asthma self-management action plan and we will also consider it in the under 5s. In it, we will explain that pollution can trigger or exacerbate asthma, and we will include in the personalised action plan approaches for minimising exposure to indoor and outdoor air pollution.

There is separate guidance on how to minimise exposure to air pollution and I will put details to this in the episode description.

Within a self-management programme, and when asthma control deteriorates, we will offer an increased dose of ICS for 7 days to adults who are using an ICS in a single inhaler. We will clearly outline how and when to do this, and what to do if symptoms do not improve. When increasing ICS treatment:

·      We will consider quadrupling the regular ICS dose

·      But we will not exceed the maximum licensed daily dose. 

For children aged 5 to 16, their self-management plan should include advice on contacting a healthcare professional for a review. If they have not been taking their ICS consistently, we will explain that restarting regular use may help them to regain control of their asthma and that the evidence for increasing ICS doses to self-manage deteriorating asthma is limited in this age group. 

NICE has given a short explanation of why they have changed the recommendation on increasing ICS treatment within a self-management programme in children. I will put details of this in the episode description in case that you are interested.

Also, we will try to identify people with asthma who are at increased risk of poor outcomes (for example, severe exacerbations or hospitalisations), and we will use this information to optimise their care. We will base the risk stratification on factors such as non-adherence to treatment, psychosocial problems and repeated episodes of unscheduled asthma care

When it comes to decreasing maintenance therapy

We will consider doing so when the asthma has been controlled for at least 3 months, updating their asthma action plan and discussing the possible effects and how to monitor them. 

When reducing maintenance therapy, we will only consider stopping ICS treatment completely for those on low dose ICS alone who are symptom free. 

In terms of the ongoing management of asthma

If control is poor, we will at every review:

·      check adherence, inhaler technique and whether the treatment needs to be changed

·      and ask about occupational asthma, if relevant. 

For the monitoring of symptoms in adults we will consider using a validated questionnaire (for example, the Asthma Control Questionnaire or Asthma Control Test). In addition, at each review for everyone aged 5 or over, we will assess control using either spirometry or peak flow variability testing. However, we will not routinely use FeNO or challenge testing for monitoring purposes. 

And finally, we will check the inhaler technique:

·      at every asthma consultation

·      when there is deterioration

·      when the device is changed

·      at every annual review

·      if the person asks for it to be checked. 

We have come to the end of this episode. I hope that you have found it useful. Thank you for listening and good-bye