All asthma reviews should consider not only patients' current control of the condition, but also factors that significantly drive up risk of an attack - including history of previous asthma attacks, poor current control of their asthma, and overuse of reliever medication, the latest advice says.
Under an updated guideline from the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), GPs are also advised to be aware of factors that can ‘moderately’ or ‘slightly’ increase risk.
In children these include having an allergic disease as well as asthma, younger age, obesity and exposure to environmental tobacco smoke, while in adults older age, female gender, reduced lung function, obesity, smoking and depression are markers of slightly increased risk.
The latest guideline from BTS/SIGN is at odds with asthma advice published in 2017 by NICE, but in a statement issued alongside the updated guideline, the three organisations have announced 'that future UK-wide guidance for the diagnosis and management of chronic asthma in adults, young people and children will be produced jointly by the three organisations'.
Dr John White, BTS member and consultant respiratory physician at York NHS Foundation Trust, who co-chaired the group that wrote the updated BTS/SIGN guideline, told GPonline he welcomed the move to 'go back to one consistent piece of advice'.
The latest BTS/SIGN guideline does not recommend 'routine use of FeNO testing in adults or children except in specialist asthma clinics'. NICE advice, however, says doctors should 'offer a FeNO test to adults (aged 17 and over) if a diagnosis of asthma is being considered', and in some circumstances for children.
The planned joint advice - which Dr White said may be at least two years away - is expected to form part of a wider set of guidance and materials produced by BTS, SIGN and NICE, on diagnosing and managing asthma throughout an individual’s lifetime – a new ‘asthma pathway’.
The updated BTS/SIGN advice urges NHS leaders to tackle inequalities in asthma outcomes by 'developing proactive plans to reach people with uncontrolled asthma' - including those from vulnerable or poorer backgrounds.
The latest advice suggests clinicians should consider quadrupling doses of inhaled corticosteroids at the onset of an asthma attack and potentially maintaining this for up to a fortnight if necessary 'to abort the attack and the need for ongoing oral steroids'. Clinicians are advised to 'weigh up the benefit/risk ratio of the strategy in people already on high dose inhaled corticosteroids'.
Patients whose asthma symptoms remain problematic after use of inhaled corticosteroids can be prescribed an inhaled long-acting beta agonist (LABA) as an add-on treatment, with a potential switch to a higher-dose inhaled corticosteroid the next option.
A leukotriene receptor antagonist can also be considered as an add-on treatment at this stage, the advice says.
In the small number of cases where asthma is not controlled with standard options, the BTS/SIGN guideline now recommends that 'all patients whose asthma is not adequately controlled on recommended initial or additional controller therapies should be referred for specialist care'.
The guidance also backs use of inhaler types with a lower carbon footprint - such as dry powder inhalers - where they are likely to be of equal effectiveness, and says patients should be asked to try to recycle their inhalers. It also offers advice on breathing exercise programmes and stop smoking support.
Dr White said: ‘At the heart of the new guideline is a drive towards providing more tailored and personalised care to help people manage their asthma effectively and reduce acute illness from the condition. The advice on how to predict an individual’s future asthma attack risk will support the NHS to identify those most likely to face potentially life-threatening attacks and deliver specific strategies to prevent this.
'This important work will support the NHS long-term plan’s aim to reduce health inequalities and variations in care that occur across different communities and parts of the country.
'The guideline also underlines previous messages that are pivotal to combatting asthma, for example, it is critical that all asthma patients have a personalised action plan and their symptoms, medication and inhaler technique are monitored on an appropriate basis.'