Asthma Guidelines in Adults


We all think we know what asthma is. As a matter of fact, we probably think we know what asthma is now more than ever...or do we?

Asthma can be defined as a common and potentially serious chronic disease that imposes a substantial burden on patients, their families and the community. It causes respiratory symptoms, limitation of activity, and flare-ups (attacks) that sometimes require urgent health care, and may be fatal. Asthma has also been defined by the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction.1,2 More recent descriptions of asthma, in both children and adults, have included airway hyper-responsiveness and airway inflammation as components of the disease reflecting a developing understanding of the diverse subtypes (phenotypes and endotypes) of asthma and their underpinning mechanisms.2 Despite these definitions, we are still finding as many as 13% of patients on the asthma register without confirmed diagnosis.

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2019 has been a very exciting year for asthma


In April, the Global Initiative of Asthma (GINA) guidelines were updated with some major paradigm shifts in asthma management; and in July, the BTS issued their update on asthma guidelines. However, does this make the diagnosis, more specifically, the management of asthma any easier…? Probably not!

We already had some major conflict in asthma guidance between NICE 2017 guidelines, and the BTS/SIGN guidelines; but with the new GINA guidelines, there is now even more conflict!

So where do we go from here, and what guidelines should we follow? The answer to this is… I am not sure!


This article will not advocate for the use of one set of guidelines over another, as this decision can only be in the hands of the physician treating the patient; however it aims to highlight the differences (and similarities) in these guidelines.

Diagnosis of asthma

NICE 2017
Algorithm A and C
BTS 2019 GINA 2019
Diagnostic
recommendations for asthma
- A good emphasis on patient history and on the key role of objective testing.
- The guidance includes some good information on the diagnostic threshold for various tests (see Table 1 in the guidelines).
- Emphasis on the importance of good history with the presence of variable symptoms, stressing on the importance of patient history vs. tests (as test results can change over time). - Emphasis on history and examination, with particular attention to variability in symptoms.
- Guidance is generally similar to the BTS in relation to using spirometry, PEFR monitoring, and reversibility testing.
Recommended
clinical assessments
- Fractional exhaled nitric oxide (FeNO) testing and spirometry have been recognised as good
first tools followed by the value of reversibility testing.
- Special objective testing can be limited by false negative values (i.e. FeNO false negative value is around 20%). Results of objective testing should be compared with and without symptoms at the time a test is done
- Detailed description of eosinophilic asthma is given; and the role of blood/sputum, eosinophils, and skin prick testing (SPT) in identifying eosinophilic asthma.
- Includes a detailed look at the diagnostic value of each symptom and test (see Table 1 Page 16 in the guidelines).
- Special diagnostic route to quickly deal with those who are symptomatic is presented, suggesting the need for urgent intervention, to fast-track their therapy options.
Pros Comprehensive with good mention of innovative methods like using diagnostic hubs in the community. Pragmatic, and diagnostic algorithms include an area in the middle for diagnostic uncertainty. It also recommends using the lower limit of normal (LLN) to avoid misinterpretation of obstructive spirometry. Addresses symptomatic cases with the need for urgent decision on therapy. There is also a section on how to investigate uncontrolled asthma.
Cons A complex algorithm, which makes it less likely to be adopted in primary care. Nothing in the guidance to allow fast tracking symptomatic patients or urgent cases within the treatment pathway. Does not provide that pragmatic approach for those with an uncertain diagnosis.

Non-pharmacological management of asthma

NICE 2017 BTS 2019 GINA 2019
Main principle Review and adjust. Comprehensive guidance on primary and secondary prevention of events taking into account important issues like allergen avoidance and management of obesity in asthmatics, to also talking about less commonly known interventions like air ionisers, fish oils, antioxidants, Vit D and acupuncture. Assess, adjust and review.
General recommendations All three guidelines offer similar recommendations within this section and that addresses the following:

1. Importance of asthma action plans and supporting self-management
2. Supporting smoking cessation
3. Avoidance of NSAIDs
4. Supporting physical activity
5. Early identification and management of co-morbidity
6. Identifying and addressing poor adherence to therapy
7. Identifying and managing poor inhaler technique
8. Addressing psychological and environmental factors


Pharmacological management of asthma

NICE 2017 BTS 2019 GINA 2019
Main principle Mild asthma: early introduction of leukotriene antagonists (LTRA). Mild asthma: use regular maintenance inhaled corticosteroids (ICS) with a slow increase in dose over time. Mild asthma: early introduction of anti inflammatory reliever therapy (AIR) on an as required basis (not licensed in Europe).
General recommendations 1. SABA can be used as needed (PRN) as a first step
2. Start low dose ICS after SABA PRN
3. Add LTRA to ICS
4. Add LABA to ICS (LTRA can be stopped based on response) if remains uncontrolled
5. Consider low dose ICS + maintenance and reliever therapy (MART) if remains uncontrolled.

Consider step down when symptoms stable for 3 months.
1. SABA can be used PRN as a first step
2. Low dose ICS can be considered with SABA PRN
3. Add LABA to ICS
4. Increase the dose of ICS (consider starting LTRA)
5. MART can be used in step 3 and above

Consider step down when symptoms stable.
1. SABA is not recommended on its own for mild asthma (all patients should receive ICS containing medication). Start AIR as required.
2. Continue AIR as required
3. Move to MART
4. Increase the dose of ICS when symptoms worsen

Consider step down if stable within 3 months
Other considerations - NICE uses symptom frequency to define control (≥daytime symptoms; ≥day/week using SABA; ≥night/week awakening).
- NICE recommends increasing (quadrupling) ICS dose for 7 days when symptoms worsen to avoid an exacerbation.
- Difficult asthma is given special attention.
- BTS considers >1 canister of SABA use per month as a marker for poor control.
- Quadrupling the dose of ICS for up to 14 days is recommended when symptoms worsen to avoid an exacerbation (however, in adherent patients, the BTS suggests there is a limited value of this intervention).
- The main focus of GINA is on preventing exacerbations, which can happen even in patients with mild asthma.
- GINA considers ≥3 canisters of SABA per annum as a marker of poor control.
- GINA recommends increasing dose of ICS when symptoms worsen.
- There is now more focus on phenotypic identification in patients requiring Step 5 treatment.

Pros Early introduction of LTRA may be of benefit in those with poor inhaler technique. Simple, comprehensive, and well-known guidance with no major changes to previous versions. Offers a new approach in managing patients with mild asthma, which may be beneficial in patients with poor compliance, using AIR therapy driven by symptoms.
Cons Algorithm is complex and flow of therapy from one step to the other is not straightforward. Does not address AIR in mild asthma in light of new evidence (Bateman 2018; O’Byrne 2018; Beasley 2019). AIR is not licensed in Europe for mild asthma, and the treatment algorithm can be complex to follow.


Monitoring of asthma

NICE 2017 BTS 2019 GINA 2019
General recommendations NICE suggests regular review of:

- Inhaler technique and adherence
- Symptoms using validated questionnaires like asthma control test (ACT) or asthma control questionnaires (ACQ)
- The need to change therapy

NICE does not recommend the routine use of FeNO in monitoring asthma unless in those who are uncontrolled on ICS.
- There is a particular emphasis on adherence to medications.
- The BTS/SIGN guidelines recommend the regular use of questionnaires like the Royal College of Physicians 3 Questions questionnaire, ACT, or ACQ (see Table 8 Page 32 in the guidelines).
- There is an emphasis on predicting risk of exacerbations (see Table 9 page 39 in the guidelines).
- The use of regular testing like PEFR monitoring or spirometry can be useful.

The BTS does not recommend the routine use of FeNO testing in primary care, and only recommends it in specialist clinics. Sputum Eosinophils assessments are not routinely recommended.
- GINA uses the principles of “Choose, Check, Correct, and Confirm” to support accurate inhaler technique, recognising that as many as 50% of patients with mild asthma do not take their medications as intended.
- GINA recommends a follow-up in 1-3 months after every treatment change, then 3-12 monthly follow-ups thereafter.
- Additional emphasis on step up/down therapy.
- Lung function to be checked 3-6 monthly initially then 1-2 years after; with education of patients to self-monitor symptoms using PEFR.
Pros Appears to be pragmatic and simple. Comprehensive and detailed. Provides good guidance on follow-up and testing intervals, which appear quite optimistic.
Cons Little if any mention on the identification of exacerbation risk. Not much to criticise here. Considering this is an international guidance, there is no mention of the role of smart PEFR meters or smart inhalers in supporting monitoring of patients.


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Conclusion

As noted above, these guidelines project some significant differences in their approach to managing Asthma; but also with some significant agreements. Unfortunately, we do not currently have evidence to support that following certain guidelines delivers better outcomes to patients. Guidelines can be a great reference point, as they are evidence based and usually produced following robust scientific methodology. However, choosing the best therapy we can offer to a patient in clinic or at the surgery is not always straight forward; and certainly not always guideline-based!

We know from evidence that clinicians are not always good at following guidelines, either because of lack of knowledge of the guidelines themselves, or of their existence; as there are far too many guidelines for too many conditions. The problem becomes even bigger for primary care physicians who are challenged by having to deal with a wide diversity of clinical conditions. Therefore, it is not surprising to find many clinicians default to their own experience and past knowledge; which can be different to guidelines (for example the choice of a certain antibiotic to treat chest infections contrary to what local Microbiology guidelines recommend, because one cannot simply remember what is recommended, and there is no time to check!). 

Therefore, combining one’s experience with guideline recommendation is a recipe that may work, but can also lead to significant variation in practice. Therefore, and although I cannot advise of which guidelines to choose here, I can say, whichever you chose, make sure you are using the ones you know best and trust the most!

References
Date of access of all websites: October 2019
  1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2019. Available from: www.ginasthma.org
  2. BTS/SIGN. British Guideline on the Management of Asthma. 2019. https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-guideline-for-the-management-of-asthma-2019/
  3. NICE. Asthma: diagnosis, monitoring and chronic asthma management. 2017. https://www.nice.org.uk/guidance/ng80/resources/asthma-diagnosis-monitoring-and-chronic-asthma-management-pdf-1837687975621
  4. O'Byrne PM, FitzGerald JM, Bateman ED, Barnes PJ, Zhong N, Keen C, Jorup C, Lamarca R, Ivanov S, Reddel HK. Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma. 2018. N Engl J Med. 2018 May 17;378(20):1865-1876.
  5. Bateman ED, Reddel HK, O'Byrne PM, Barnes PJ, Zhong N, Keen C, Jorup C, Lamarca R, Siwek-Posluszna A, FitzGerald JM. As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma. N Engl J Med. 2018 May 17;378(20):1877-1887.
  6. Beasley R, Holliday M, Reddel HK, Braithwaite I, Ebmeier S, Hancox RJ, Harrison T, Houghton C, Oldfield K, Papi A, Pavord ID, Williams M, Weatherall M; Novel START Study Team. Controlled Trial of Budesonide-Formoterol as Needed for Mild Asthma. N Engl J Med. 2019 May 23;380(21):2020-2030.

Dr Nawar Bakerly MD, FRCP has received an honorarium from GSK for developing this article/content.

PM-GB-CPU-WCNT-190019 October 2019

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PM-GB-CAU-WCNT-190006
March 2019