2019 has been a very exciting year for asthma
Diagnosis of asthma
Algorithm A and C
|BTS 2019||GINA 2019|
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.
|- 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.|
Date of access of all websites: October 2019
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2019. Available from: www.ginasthma.org
- 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/
- 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
- 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.
- 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.
- 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.