The updated BTS/SIGN guideline advises clinicians to consider quadrupling the dose of inhaled corticosteroids at the onset of an asthma attack and maintaining this for up to a fortnight if necessary to abort the attack and the need for ongoing oral steroids.
The benefit/risk ratio of this strategy should be assessed in people already on high-dose inhaled corticosteroids.
Patients whose asthma symptoms persist after use of inhaled corticosteroids can be prescribed an inhaled long-acting beta agonist (LABA) as an add-on treatment, with a potential switch to a higher-dose inhaled corticosteroid the next option.
A leukotriene receptor antagonist can also be considered as an add-on treatment at this stage, the guideline says.
Healthcare professionals should consider the option of combined maintenance and reliever therapy in adults who have a history of asthma attacks on medium dose ICS or ICS/LABA.
In the small proportion of cases where asthma is not adequately controlled on the recommended initial or additional controller therapies, the guideline now recommends that patients be referred for specialist care.
The guidance also recommends the use of inhaler types with a lower carbon footprint - such as dry powder inhalers - where they are likely to be equally effective, and says patients should be encouraged to recycle their inhalers. It also offers advice on breathing exercise programmes and smoking cessation support.
Preventing asthma attacks
A key focus of the updated guidance is preventing future asthma attacks by assessing each patient's risk and tailoring their monitoring, treatment and care accordingly.
Asthma reviews should assess not only patients' current control of their condition, but also factors that significantly drive up risk of an attack - including previous asthma attacks, poor current control, and overuse of reliever medication, the latest advice says.
GPs are also advised to be aware of factors that can 'moderately' or 'slightly' increase risk. In children these include having an allergic disease as well as asthma, younger age, obesity and exposure to tobacco smoke, while in adults older age, female gender, reduced lung function, obesity, smoking and depression are markers of a slightly increased risk.
Quick-reference MIMS summaries of the BTS/SIGN guidance have been updated to reflect the new recommendations.
Joint NICE guidance
The latest guideline from BTS/SIGN differs from asthma advice published in 2017 by NICE. Among other differences, BTS/SIGN do not recommend routine use of FeNO testing in non-specialist settings whereas NICE says doctors should offer a FeNO test to adults if a diagnosis of asthma is being considered (and in some circumstances for children).
However, in a statement published alongside the updated guideline, the three organisations have announced that they will jointly produce future UK-wide guidance for the diagnosis and management of chronic asthma in adults, young people and children.
The planned joint advice is expected to form part of a set of guidance and materials produced by BTS, SIGN and NICE, on diagnosing and managing asthma throughout an individual’s lifetime – a new 'asthma pathway'.