NICE has published a new guideline on the diagnosis, monitoring and management of asthma. This is an overview of the recommendations for GPs and their teams.
Initial assessment
GPs should use an objective test to diagnose asthma, not symptoms alone.
Patients should be treated immediately if they are acutely unwell at presentation and objective tests for asthma should be performed if the equipment is available.
Check for possible occupational asthma. Refer those with suspected occupational asthma to an occupational asthma specialist.
For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review on a regular basis. If they still have symptoms when they reach age 5, carry out objective tests.
Diagnosis
CCGs should consider establishing asthma diagnostic hubs to achieve economies of scale and improve implementation of NICE’s recommendations.
Offer a FeNO test to adults if a diagnosis of asthma is being considered. A FeNO level of 40 parts per billion (ppb) or more is a positive test.
Consider a FeNO test in children and young people (aged 5 to 16) if there is diagnostic uncertainty after initial assessment.
Offer spirometry to adults and children aged 5 and over if a diagnosis of asthma is being considered. A FEV1/FVC ratio of less than 70% (or below the lower limit of normal if this value is available) is a positive test for obstructive airway disease (obstructive spirometry).
Offer a bronchodilator reversibility test to adults with obstructive spirometry and consider one in children with obstructive spirometry.
Monitor peak flow variability for 2 to 4 weeks in adults and children if there is diagnostic uncertainty after initial assessment and a FeNO test.
Offer a direct bronchial challenge test with histamine or methacholine to adults if there is diagnostic uncertainty after a normal spirometry and a FeNO level of 40 ppb or more and no variability in peak flow readings or FeNO level of 39 ppb or less with variability in peak flow readings. A PC20 value of 8 mg/ml or less is a positive test.
Treatment and monitoring
Offer a short-acting beta-2 agonist (SABA) as reliever therapy to adults newly diagnosed with asthma.
For those with infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone.
Offer a low dose of an inhaled corticosteroid (ICS) as the first-line maintenance therapy.
If asthma is uncontrolled on a low dose of ICS, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review in four to eight weeks.
If asthma is uncontrolled on a low dose of ICS and an LTRA, offer a long-acting beta-2 agonist (LABA) in combination with the ICS.
If asthma remains uncontrolled on a low dose of ICS and a LABA, with or without an LTRA, offer to change the person's ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose.
If asthma is uncontrolled on the above, consider increasing the ICS to a moderate maintenance dose.
If asthma is still uncontrolled, consider increasing the ICS to a high maintenance dose (this should 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).
Consider decreasing maintenance therapy when a person's asthma has been controlled with their current maintenance therapy for at least 3 months.
Monitor asthma control at every review. Do not routinely use FeNO to monitor asthma control.
Consider FeNO measurement as an option to support asthma management in people who are symptomatic despite using ICS.
