Clash between respected asthma guidelines risks confusion for GPs

Significant differences between NICE's new asthma guidance and established 'gold standard' BTS/SIGN advice could cause confusion among GPs, respiratory specialists have warned.

NICE said at the launch of its long-awaited guideline that it intended to work alongside BTS/SIGN to determine ‘how it might be possible in the longer term’ to develop a single, cohesive set of guidance.

But it may prove difficult to reconcile the two, as experts from the Primary Care Respiratory Society (PCRS) have highlighted marked differences betweent the two sets of recommendations for diagnosing and managing asthma.

NICE’s guideline, launched on Wednesday, recommends the standardised use of objective tests including spirometry, FeNO testing and peak flow management to diagnose asthma.

But the BTS/SIGN guidance, last updated in 2016, criticises the use of objective tests to diagnose asthma, warning that tests such as spirometry and FeNO may result in false negatives if taken when a patient is asymptomatic or during an ‘inactive’ period.

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Instead, it advocates the use of diagnostic tests carried out when the patient is both symptomatic and asymptomatic to detect variation over time.

It adds that these tests do not necessarily preclude an asthma diagnosis, and patients considered to have a high probability of asthma should be given treatment for a period and carefully monitored.

The PCRS said it was concerned that the contrasting recommendations would create uncertainty for primary care clinicians over how to approach asthma diagnosis and management.

It warned that the NICE guidance differs on diagnosis and management advice from the BTS/SIGN recommendations, which have set the evidence-based standard for the UK since 2003.

Confusion for GPs

PCRS experts highlighted concerns about NICE advice advocating 'greater reliance on objective testing at a single point in time', warning it could increase risk of false positive or negative tests. NICE guidance could increase referrals to secondary care, the group fears, and differs from existing advice in its recommended first-line treatment options if inhaled corticosteroids are ineffective.

Dr Duncan Keeley, PCRS-UK Policy Lead says: ‘NICE is an excellent organisation which plays a vital role in improving the cost effectiveness of our health services. But PCRS UK has always questioned the wisdom of seeking to replace the widely respected BTS/SIGN guideline for asthma - which was itself approved by NICE.

‘We feel it would be better for NICE to contribute its expertise in cost benefit analysis to the options in the existing comprehensive BTS/SIGN guideline rather than seeking to replace it. There is a strong preference in the primary care community for a single comprehensive asthma guideline for the four nations of the UK.’

NICE’s director of the centre for clinical guidelines, Dr Mark Baker, said: ‘NICE intends to explore with BTS/SIGN how it might be possible in the longer term to develop a comprehensive guideline on asthma that incorporates elements of those from both NICE and BTS/SIGN.’

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