Step 2 of the BTS/SIGN guidelines1 on the management of asthma in adults recommends the introduction of regular preventer therapy with inhaled corticosteroids.
Add-on therapy (Step 3) involves the introduction of an additional therapy, the first choice of which is an inhaled long-acting ß2-agonist (LABA).
The new NICE guidance recommends the following:
- For patients with chronic asthma in whom an inhaled corticosteroid is considered appropriate the least costly product should be prescribed, assuming that the product is suitable for the individual and is prescribed within its licence.
- For patients in whom treatment with both an inhaled corticosteroid and a LABA is considered necessary the use of a combination inhaler device is an option. In this instance the least costly product that is suitable for the individual should be prescribed.
- The decision on whether to use a combination device or the two agents in separate devices should be made on an individual basis, taking into consideration therapeutic need and the likelihood of treatment adherence.
Following a review of the available evidence the NICE appraisal committee concluded that when comparing the different inhaled corticosteroids, either at low or high doses, there was no difference between them in terms of effectiveness. It also concluded that adding a LABA is more effective than continuing on the same or an increased dose of inhaled corticosteroid.
When considering simultaneous treatment with an inhaled corticosteroid and a LABA the committee concluded that it was reasonable to assume that there was no significant difference in effectiveness when these were administered in a combination device as opposed to separate devices. However, it accepted that the use of a single combination device is likely to be associated with significantly improved adherence.
The full guideline is available at www.nice.org.uk