BTS/SIGN asthma guidance updated with new treatment recommendations

The 2016 edition of the Scottish Intercollegiate Guidelines Network (SIGN) and the British Thoracic Society (BTS) guideline on the management of asthma sees significant changes to the recommendations on diagnosis and treatment of the condition, including the addition of suggested doses for specific steroid inhalers.

GPs should only prescribe inhalers after patients have received training in the use of the device and have demonstrated satisfactory technique. | iSTOCK
GPs should only prescribe inhalers after patients have received training in the use of the device and have demonstrated satisfactory technique. | iSTOCK

Updates to the latest version of the BTS/SIGN guidelines on the management of asthma include a major revision of the section on pharmacological management of asthma, with treatment stages no longer being referred to as numbered steps.

New tables provide specific recommended doses for each metered-dose and breath-actuated inhaler in adults and children, replacing the previous guidance on equivalent dosing of inhaled corticosteroids relative to beclometasone dipropionate.

In children, there is now a single treatment flowchart covering all ages.

The updated guidance highlights that inhalers should be prescribed by brand name to prevent people being given an unfamiliar inhaler device that they are not able to use properly.

Add-on asthma therapy

A long-acting anticholinergic (or antimuscarinic; LAMA) is now suggested as an option for add-on treatment in adults if control remains inadequate when a long-acting β2 agonist (LABA) is added to low-dose inhaled corticosteroids.

If control in adults remains inadequate on medium-dose inhaled corticosteroids plus a LABA, addition of the LAMA tiotropium can be considered.

Maintenance and reliever therapy with a combined corticosteroid/LABA inhaler can be considered for adults who have a history of asthma attacks on medium-dose inhaled corticosteroids or inhaled corticosteroids plus a LABA.

In children from 5 years, a leukotriene receptor antagonist is now a possibility for initial add-on therapy instead of a LABA.

The anti-IgE antibody omalizumab (Xolair) may be considered within its licensed indication for patients with IgE-mediated asthma who have a high steroid burden.

Diagnosis of asthma

The section of the guidance covering asthma diagnosis has been fully revised for 2016.

The revised diagnosis section now advises a structured clinical assessment using a combination of patient history, examination and tests to assess the probability (high, intermediate or low) of asthma.

Clinicians are also reminded that an individual's asthma status can change over time. To detect such changes, the guideline recommends comparing the results of diagnostic tests undertaken while the patient is asymptomatic and with those undertaken when the patient is symptomatic.

The new guideline emphasises that there is still no single test that can definitively diagnose asthma.

The MIMS summary of the guidance is currently being updated and will be available online shortly and in the print issue for December.

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