Long-awaited joint UK guidelines for chronic asthma have been finalised, overhauling diagnosis and treatment recommendations in an effort to better manage the condition in primary care and reduce pressure on hospitals.
The final chronic asthma guidance from the National Institute for Health and Care Excellence (NICE), British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) is designed to support clinicians in making accurate diagnoses, promoting good practice, and providing effective, personalised treatment to control and prevent acute asthma attacks.
This is the first time the organisations have collaborated to produce joint UK-wide guidance on the diagnosis and management of chronic asthma for adults, young people and children.
Alongside its publication, NICE, BTS and SIGN have also developed a new joint asthma pathway. This digital resource collates tools and information for in a central hub, providing ‘a seamless user journey across the newly published guideline and existing asthma guidance‘.
Final chronic asthma guidance
In June, draft guidance revealed significant changes to the current treatment approaches. This included replacing the sole use of short-acting beta agonist (SABA) when asthma is first diagnosed with a low-dose combination of inhaled corticosteroids (ICS) and formoterol, which the final guidance has now reinforced.
Indeed NICE emphasised that healthcare professionals should ‘always prescribe maintenance or combination treatments’ rather than the ‘familiar blue “reliever-only” inhaler, when asthma is first diagnosed’.
This is based on evidence which ‘showed that using the combined ICS and formoterol inhalers when required led to people suffering fewer severe asthma attacks’.
The final chronic asthma guidance has also confirmed changes to recommendations on testing for asthma, with a new recommendation to use peak expiratory flow (PEF) variability as a method for diagnosis, which has been added following consultation.
It advised healthcare professionals to use a stepwise series of tests including eosinophil count, FeNO, spirometry and bronchial challenge in patients where the condition is suspected on clinical grounds.
However, NICE warned that these tests – recommended for both children and adults – are ‘not routinely carried out in current practice’, with ‘only a minority of GP practices’ having onsite access to FeNO tests, while bronchial challenge testing is not available at all in primary care.
As such, NICE recognised that there will be a ‘capacity problem’ and that implementing the recommended diagnostic pathway into clinical practice would ‘require significant investment’.
Another addition to the joint guidance following consultation was a recommendation to consider providing an additional metered SABA inhaler plus spacer for emergency use for children under 12 years who may be unable to activate a dry powder inhaler during an acute asthma attack.
Easing pressure on the NHS
NICE’s chief medical officer Professor Jonathan Benger said the new guidance aims to ‘ease pressure’ on the NHS by ‘reducing hospital admissions due to asthma and lowering the use of less effective monitoring tests’.
He continued: ‘Having one clear set of national asthma guidelines is vital to ensure people receive consistent and effective asthma care across the health service, so people across the UK receive the right diagnosis and treatment for them.’
BTS chair Dr Paul Walker said the changes to recommendations for testing ‘will simplify diagnostic processes and help with current diagnostic delays for adults, children and young people’.
‘The treatment changes represent a true pivot in the principles of asthma care and will contribute to improved outcomes,’ he added.
Dr Andy Whittamore, GP and Asthma and Lung UK clinical lead, said the new guidelines ‘have the potential to make a real difference’ to the 7.2 million people in the UK living with asthma.
He said the recommendation to ‘move away from over-reliance’ on SABA inhalers, which is a ‘key driver of poor asthma control’, is ‘particularly welcome’.
Dr Whittamore also highlighted that the changes to diagnostic recommendations will ‘need to be accompanied by good clinician education to ensure they can confidently and reliably work within the new diagnostic pathway’.
On resourcing for testing, he added: ‘It is very positive that the guidelines acknowledge the difficulties in diagnosing asthma correctly and identify poor access to FeNO and spirometry testing as a barrier that can block safe, good quality care.
‘Funding must be made available to support healthcare professionals to deliver these tests and make them available for every person with suspected asthma.’
Supporting better patient care
Chair of the Primary Care Respiratory Society Dr Katherine Hickman, who is also a GP in Bradford, said the new guidelines ‘introduce a systematic and evidence-based approach to diagnosis’ and she is ‘confident these recommendations will help ensure more accurate assessments and better patient care’.
She continued: ‘One of the most promising advancements is the move towards anti-inflammatory reliever therapy (AIR) and maintenance and reliever therapy (MART).
‘This innovative approach marks a significant shift in asthma treatment, offering new hope to patients and healthcare providers alike. It has the potential to transform how we manage asthma by reducing the burden on primary and secondary care, saving lives, and restoring control to patients over their condition.
‘The guidelines give me real hope for the future of asthma care. They represent a critical step in not only improving patient outcomes but also reshaping how asthma is managed at every level of the healthcare system.’
However, Dr Hickman advised GPs that no patient should be switched to a new inhaler without an ‘informed discussion’.
Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London, said the recommendation to replace SABA inhalers alone with combination inhalers ‘reflects evidence that this approach can improve overall asthma control’.
He also said the new recommendations on testing will ‘help reduce misdiagnosis and ensure that treatment is appropriate’, but he warned that implementing the joint guideline will ‘require significant investment to ensure widespread access’ to diagnostic methods such as FeNo and spirometry.
Professor Majeed continued: ‘Another concern is ensuring that all patients, regardless of where they live, have equitable access to the recommended tests. Currently, geographic disparities exist in diagnostic capabilities, which could lead to unequal implementation and outcomes between areas.
‘Overcoming capacity and implementation challenges will require investment in diagnostic infrastructure; workforce expansion and training; and collaboration across primary and specialist care.’
Earlier this month, a report from UCLPartners revealed that an app to assist with asthma self-management could save the NHS up to £25m in a year if it were used by 100,000 patients for three months.
In February 2024, the BTS and Primary Care Respiratory Society published a position statement on integrated respiratory care models and the importance of putting patients at their centre.
A version of this article was originally published by our sister publication Pulse.
