NICE asthma guidance sets out plan to overhaul treatment and diagnosis

Long-awaited NICE guidance on asthma has set out plans for a significant overhaul of treatment and diagnosis of the condition, but clashes with existing advice and could prove impossible for GPs to implement immediately.

Spirometry (Photo: Lewis Houghton/Science Photo Library)
Spirometry (Photo: Lewis Houghton/Science Photo Library)

NICE said its proposed asthma shake-up – which has been nearly five years in the making – should allow the NHS to save between £10m and £15m over the next five years, mainly through slashing unnecessary prescriptions.

It calls for objective testing with spirometry and FeNO - a step it calls a ‘significant enhancement to current practice’ - but admits this will take some time to become established in general practice.

The GPC has welcomed advice from NICE that GPs should 'implement what they can' of the new guidance until infrastructure and training in primary care catches up to allow them to adopt the rest.

Asthma diagnosis

However, specialist groups including the Primary Care Respiratory Society (PCRS), have criticised NICE’s recommended diagnosis pathway, warning that it clashes with established guidance, muddying the waters and potentially creating confusion for GPs.

Read more
 Clash between asthma guidelines risks GP confusion
> A summary of NICE's asthma guidance
> Medico-legal: The legal status of guidelines

The guidance also makes recommendations on managing asthma. In a shift from current practice, it says patients whose symptoms remain uncontrolled on inhaled corticosteroids (ICS) alone should be offered a leukotriene receptor antagonist (LTRA) as the next course of action.

Long acting beta-agonist (LABA) treatment – currently recommended as the first-line course of treatment if preventer inhalers are insufficient – should then be offered if the patient’s asthma remains uncontrolled after this.

GPC clinical and prescribing lead Dr Andrew Green said:  ‘The new NICE guidance on asthma represents a significant change to current management pathways, and we are pleased that both NHS England and NICE recognise that investment will be required to make these changes happen.

Diagnosis and treatment

‘Their statement that GPs should continue with current diagnostic methods during the transition period is vital both to protect GPs and to ensure system stability.

‘When the proposed locality hubs are commissioned it is essential that they provide a full respiratory testing service to cover all aspects of the diagnostic process.

‘This opportunity should be taken to ensure that the on-going spirometry requirements of patients are also addressed and provided to the latest quality standards, as in many areas GPs are carrying out this work without appropriate resources.’

Professor Mark Baker, director of the centre for guidelines at NICE, said: ‘We are recommending objective testing with spirometry and FeNO for most people with suspected asthma; a significant enhancement to current practice, which will take the NHS some time to implement, with additional infrastructure and training needed in primary care.

‘New models of care, being developed locally, could offer the opportunity to implement these recommendations. This may involve establishing diagnostic hubs to make testing efficient and affordable. They will be able to draw on the positive experience of NICE’s primary care pilot sites, which trialled the use of FeNO.

‘The investment and training required to implement the new guidance will take time. In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.’

He added: ‘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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