Delayed NICE guidance on asthma diagnosis may cause problems for GPs

NICE guidance on diagnosing asthma could be published this week after nearly five years in development, but looks set to clash with existing advice - potentially leaving GPs unclear over best practice.

Spirometry (Photo: Lewis Houghton/Science Photo Library)

NICE first began work on the guideline in 2012 and initially published a draft version of the recommendations in January 2015. Final publication was delayed to allow additional time to check feasibility of the proposals.

It consulted again on the recommendations between July and August this year, and a timeline published on its website suggests the final guideline should have been published last week on Monday 30 October.

A NICE spokesman told GPonline it had been pushed back so it could discuss an implementation plan for the guidelines with NHS England and it hoped to publish them soon. No date has been confirmed, but it could be released from this week, he added.

NICE has yet to publish official guidance on asthma diagnosis, but indications from the draft guideline suggest its recommendations could clash with established guidance.

GP Dr Steve Holmes, education lead for the Primary Care Respiratory Society (PCRS) UK, warned that having two sets of different recommendations could cause problems for GPs in terms of both their own clinical decision-making and knowing what targets they are being measured against.

Read more: BTS/SIGN advice

The draft guidance recommends a standardised method of diagnosing asthma, beginning with FeNO and spirometry tests ‘if a diagnosis of asthma is being considered’ for all adult patients and children over five years old. A FeNO level of 40 parts per billion should be considered a positive test, it says.

But the latest BTS/SIGN guideline from 2016 – widely viewed as the current gold standard advice on diagnosing asthma – warns that a normal spirometry test does not preclude an asthma diagnosis, adding there 'is no single diagnostic test for asthma'.

It recommends comparing tests when a patient is asymptomatic and symptomatic before making a diagnosis.

Dr Holmes told GPonline the two guidelines appeared to be ‘relatively different’ in terms of diagnosing asthma, which could cause problems for GPs.

‘Number one, it means which one do you choose clinically? And number two, it means which one do those who monitor you recognise?' he said.

Different recommendations

‘The difficulty for a generalist is picking out which one is right – and which one is more right – and how do I choose.

‘I think most of my colleagues suggest it is easier to both clinically work and teach to one set of guidelines rather than having guidance that differs that differs between organisations.

‘There are a lot of discussions about this – the guidance for diagnosis from both organisations were effectively based on the same literature review, which does bring to mind how can two groups can use the same evidence and come to different conclusions.’

BTS published a statement online saying it had met with NICE in January this year ‘for a useful exchange of views’ about NICE’s incoming guidelines. It is expected to release a statement when NICE launches the guidance, outlining what it considers to be the way forward.

Meanwhile, it is reviewing its own guideline, which will next be updated sometime in 2019.

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