NICE asthma guidance 2017: The key points for GPs

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.

Read the full NICE asthma guideline here

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