First NICE asthma guideline recommends oral treatment before LABA

NICE suggests offering a leukotriene receptor antagonist (LTRA) for patients whose asthma is uncontrolled on a low dose of inhaled corticosteroid (ICS), in contrast to the established BTS/SIGN guidance which advises the addition of a long-acting beta agonist (LABA).

The Primary Care Respiratory Society has warned that multiple guidelines create uncertainty for clinicians and may lead to inconsistencies in the care of individual patients. | iStock

NICE has published its first clinical guideline on the diagnosis, management and monitoring of asthma, with marked differences between its recommendations and the 'gold-standard' guidance published by BTS/SIGN

The most significant difference between the NICE guideline and the BTS/SIGN asthma guideline is the recommendation relating to the first-line add-on treatment in adults when asthma is not sufficiently controlled on low-dose ICS.

NICE's recommendation is based on a health economic analysis which found that LTRAs would be more cost-effective than LABAs as first-line add-on to ICS. NICE believes there could be significant savings to the NHS by deferring the use of LABAs in favour of LTRAs.

Asthma management

As with the BTS/SIGN asthma guidance, the NICE guideline advises prescribers to 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 SABA reliever therapy alone may be sufficient.

A low dose of ICS should then be offered as the first-line maintenance therapy.

If asthma is uncontrolled on a low dose of ICS, NICE suggests offering a LTRA in addition to the ICS, and reviewing the patient in 4 to 8 weeks. If asthma is uncontrolled on a low dose of ICS and an LTRA, NICE says a LABA should be offered in combination with the ICS.

If asthma remains uncontrolled on a low dose of ICS and a LABA, with or without an LTRA, the ICS and LABA maintenance therapy can be changed to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose.

If asthma remains uncontrolled on the above, the prescriber can consider increasing the ICS to a moderate maintenance dose. If asthma is still uncontrolled, the ICS may be increased 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 can be considered (for example, a long-acting muscarinic receptor antagonist or theophylline).

Consideration should be given to decreasing maintenance therapy when asthma has been controlled with the patient's current maintenance therapy for at least 3 months.

Diagnostic testing

To diagnose asthma, NICE recommends the standardised use of objective tests including spirometry, FeNO testing and peak flow management. This diverges from BTS/SIGN guidance, which criticises the use of objective tests to diagnose asthma on the basis that these may result in false negatives if performed when a patient is asymptomatic or during an 'inactive' period. Instead, it advocates the use of diagnostic tests carried out when the patient is both symptomatic and asymptomatic to detect variation over time.

The Primary Care Respiratory Society has warned that NICE's recommendation to use FeNO in all people with suspected asthma could significantly increase costs and referrrals to secondary care, given that FeNO is not widely available in primary care.

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