Chronic asthma guideline key updates and implications: pharmacological management

In her second article on the new UK joint guidelines for chronic asthma, Ravijyot Saggu discusses the principles of pharmacological management it outlines, how new maintenance and combination treatments will contribute to improved outcomes and opportunities to work in partnership with patients to improve asthma care, and top tips for implementation.

The National Institute for Health and Care Excellence (NICE), the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), have recently come together to produce a single national guideline on the diagnosis, monitoring and management of chronic asthma.

Read more about the context around the joint guideline and its recommendations for the diagnosis and monitoring of chronic asthma in part one of this series.

When it comes to the pharmacological management of chronic asthma, notably, the guidance initiates a move away from prescribing short-acting beta-agonist (SABA) as a monotherapy.

It is known that overprescribing of SABA is not without risks.¹ SABA do not treat the inflammation seen in asthma and inhaled corticosteroids (ICS) are therefore a necessary, evidence-based part of treatment.

The pharmacological management of people aged 12 and over is summarised in a joint guideline algorithm and it is explicit that there should be no SABA prescribing without concomitant ICS prescription.²

Reminding patients and healthcare professionals of this update is important so they move away from legacy prescribing.

A fundamental recommended change is combination therapy with ICS and a long-acting beta-agonist (LABA) – specifically formoterol – in a single-inhaler device. Formoterol has a quick onset of action compared with SABA and has a longer-lasting effect,³ making a formoterol-containing regime ideal for ‘as needed’ doses.

New treatment approaches for chronic asthma

Two new treatment approaches are recommended: anti-inflammatory reliever (AIR) and maintenance and reliever therapy (MART), both of which use ICS+LABA.

The advantages of this combination include:

1 The fast-onset action of formoterol, so no requirement for concurrent SABA prescribing

2 Expected overall reduction of SABA use and its associated side effects for patients

3 A single inhaler device to carry and be trained to use

4 Allows flexibility for patients, potentially with a greater sense of ownership and control

5 Most ICS+formoterol products available are dry powder inhalers (DPI) with a lower carbon footprint and less environmental impact.

• AIR

AIRis intended for patients who have mild asthma with occasional symptoms, but patients’ perception of their disease should be assessed to ensure this regime is the most clinically appropriate option.

• MART

MART has been available for many years but is not widely used. It is a sliding-scale approach using a fixed dose of ICS+LABA twice a day plus supplementary doses to a designated maximum amount, if needed. This allows the patient to step up treatment as necessary.

It should be noted that supplementary dosing is not intended as a long-term option; instead, it is a short-term intervention if necessary. Continued use of supplemental doses suggests inadequate asthma control – and potentially harbinger of exacerbation – and should be reviewed to adjust therapy accordingly.

Beyond AIR, the guidance suggests starting on low-dose MART – usually up to 400 mcg beclomethasone diproprionate (BDP) equivalent daily – and increasing to a moderate dose of up to 800 mcg BDP equivalent, should this be warranted clinically.

The regimens do not promote high-dose ICS and, if this occurs, it warrants clinical review and onward specialist referral if appropriate. High-dose ICS is when daily doses of >1000mcg BDP equivalent are reached.⁴

While it is encouraging that no high-dose ICS use is recommended in the joint guideline, it is acknowledged that patients inadequately controlled on moderate-dose MART might inadvertently receive higher-dose ICS by using many supplementary doses.

In this case, fraction of exhaled nitric oxide (FeNO) and blood eosinophil count (BEC) tests are needed to guide further action. If either is raised, and all modifiable factors optimised, the patient should be referred for review by an asthma specialist.²

While MART is a pragmatic treatment approach for most patients, it may not suit all. For example, some patients might be sensitive to beta-agonists or have cardiac issues, so it is important to prescribe the treatment best suited to the individual.

Providing person-centred care for chronic asthma

Achieving good asthma control requires a holistic approach following medicines optimisation principles.⁵

Person-centred care should consider individual preferences, treatment beliefs and history, using shared decision-making to agree on treatment in partnership. Tools such as the BRAN model (Benefits, Risks, Alternatives, Nothing) are helpful in structuring conversations in shared decisions about treatment.⁶

Non-adherence to medicines may be intentional or unintentional, and this should be reviewed and addressed with the patient. Non-adherence can be monitored by reviewing prescription records, looking at numbers of ICS-containing inhalers, SABA and oral corticosteroid (OCS) dispensing, as well as calculating the medicines possession ratio and reconciling these with FeNO levels, which might be raised for a number of reasons including non-adherence and poor asthma control.

Improving outcomes after an asthma attack

The BTS asthma attack bundle sets out four high-impact actions likely to improve outcomes if implemented following an asthma attack.⁷ These can be applied in any healthcare setting for adults and adolescents over 16 years transitioning to adult services.

The actions are a medication review, personalised asthma action plan (PAAP), tobacco dependence advice and support for current smokers, and clinical review within four weeks.

PAAPs and other information to support patients and healthcare professionals can be accessed from the website of the charity Asthma + Lung UK.

Chronic asthma treatment sequencing

The evidence on treatment sequencing beyond moderate-dose MART is less clear. Where there is inadequate asthma control, both FeNO and BEC should be checked, and other factors such as adherence, inhaler technique and comorbidities should be optimised. If, despite this, FeNO and BEC tests are elevated, referral to an asthma specialist is warranted.

If there is inadequate control but BEC and FeNO are not raised, a leukotriene receptor antagonist (LTRA) or long-acting antimuscarinic agent (LAMA) can be added as a trial. There is no convincing evidence of the superiority of one agent over the other; hence, choice, benefits and risks should be discussed with the patient.

The benefits of an LTRA are that it is a more economical option in England, it is available orally and is easier than adding a new inhaler and being trained on correct use. However, the recent MHRA alert on the LTRA montelukast reiterated the risk of neuropsychiatric reactions with use,⁸ so this should form part of patient shared decision-making discussions.

If the patient is controlled with the additional agent, treatment should continue. However, if control is improved but not adequate after addition, the other agent can be added, for example, if an LTRA was initially added, progress to include a LAMA.

Response to treatment should be reviewed eight to 12 weeks afterwards.

Refer to the joint guideline for further detailed information on transferring patients from existing therapies to newer guideline approaches.

Environmental considerations

Moving away from SABA use is a positive step. Apart from not targeting airway inflammation, we know certain salbutamol brands, such as Ventolin MDI, have a very high carbon footprint, as does SABA overuse and poor disease control.

An assessment of the carbon footprint of the NHS in England estimated a carbon footprint of 125 kg CO2e per bed-day and 76 kg CO2e per outpatient appointment for acute care, 66 kg CO2e per general practice visit, and 75 kg CO2e per ambulance emergency response.⁹ Good disease control has a lower environmental impact and lower CO2 emissions are expected as a result of this and lower SABA use.

Inhalers for MART are mainly available as DPI devices, which have a comparably lower carbon footprint than MDIs.

There is often a mismatch between the patient’s ability and their prescribed inhaler, usually an MDI first line, and incorrect inhaler technique is used. For example, MDIs require a deep but slow inhalation, whereas DPIs require deep and fast inspiration. DPIs are a better option and especially suited where patient inspiration is fast, thereby benefitting both patient and population health.

Patients should also be reminded to return unused, expired or old inhalers to their pharmacy for disposal or recycling rather than using domestic waste, which can adversely impact the environment.

Key guideline recommendations: a summary

The recommendations made in the joint guideline are pragmatic, with the view to simplify and improve asthma care, which is very welcomed. As the name suggests, guidelines offer a ‘guide’, however, they have to be applied whilst tailoring them to individual patient circumstances. Healthcare professionals play a key role in the optimisation and maintenance of good asthma control and can do this by understanding and applying key principles of the guidance:

• No SABA without concomitant ICS prescription in people with asthma
• Good history taking, supported by objective tests, is important
• Take an AIR or MART approach and generally move away from SABA use
• No high-dose ICS use recommended
• Referral to specialist and asthma specialist criteria outlined
• Off-label use of ICS/LABA acknowledged
• People with an existing diagnosis of asthma who are stable on their current therapy do not have to switch treatment
• People on current pathways who need an increase in treatment will be switched to MART, but this is one of the current options
• Digital inhalers not recommended routinely
• Peak expiratory flow (PEF) not to be used for routine monitoring of asthma.

Implementation and implications: chronic asthma guidelines

Healthcare professionals must become familiar with the guideline and their local inhaler formulary. The guideline presents opportunities for enhancing patient care and outcomes through greater shared decision-making conversations and improving asthma awareness while addressing concerns and illness beliefs – but this may extend consultation time.

Key points to note regarding implementation are:

• Structured clinical history taking with patients is vital, with a need to communicate clearly what maximum number of puffs per day is permissible, depending on which inhaler brand and treatment approach they are prescribed
• The guideline is clear about ‘observing’ inhaler technique, which puts less reliance on a phone review, noting the utility and role of remote consultations
• Reduction in PEF routine monitoring and increase in FeNO use is expected
• Access to some tests is variable in different settings, such as FeNO in primary care, and there may be resulting equipment costs, but these should be viewed as an investment
• Local infrastructure and service pathways vary across geographies and patients may need to be referred onwards for further diagnostic tests or specialist review. This will impact the receiving services and has potential to cause bottlenecks or delays in care pathways. Additionally, this offers opportunities to review local referral and care pathways and strengthen stakeholder relationships
• Increased interest in health and quality improvement approaches is expected and encouraged. This also contributes to improving metrics within England’s National Respiratory Audit Programme. There is also the opportunity to reacquaint with and complement valuable existing resources such as the previously mentioned BTS asthma bundle, the NHS Accelerated Access Collaborative uncontrolled asthma consensus pathway and the Greener Practice ‘High Quality and Low Carbon Asthma Care’ quality improvement toolkit
• Emergency departments will also need to review inhaler stock holdings and stock rotation, particularly for pre-labelled ‘to take away’ medicines
• Staff and patient education to ‘unlearn’ SABA prescribing and issues will be required. Timely follow-up after hospital attendance and communication at transfers of care is therefore imperative
• Identifying patients through targeted searching of primary care databases is expected to be a way to review prescribing and revisit diagnosis. This includes any patients prescribed SABA alone (stop or move to AIR if they have an asthma diagnosis) and consideration of risk stratification approaches to identify people at risk of poor asthma outcomes
• Moving existing legacy patients over to the relevant new regimen unless they are stable on their current therapy
• People on current pathways who need an increase in treatment will be switched to MART, but this is one of the current options. The guidelines state that there should therefore not be significant disruption to asthma care.

Practice points and top tips

These are some top tips on how to optimise practice in accordance with the guideline recommendations:

• Remember that an asthma attack is a warning sign: if a patient presents like this, as many do, get them onto correct therapy immediately, which may be low-dose MART, depending on the setting. Use OCS if needed acutely
• Justify and address reasons for inadequate control before escalating therapy
• Guidelines are just that: personalise management to individual needs, perceptions and practicalities in shared decision-making, and ensure each patient has a PAAP and knows how to use it
• Be holistic: consider how the patient presents, what they look like, patient patterns and ensure good history taking
• Get the essentials of care right: optimise adherence, encourage vaccination uptake, maximise consultations to discuss overall health and wellbeing, lifestyle and physical activity – including smoking cessation where applicable – and educate around environmental sustainability and correct disposal of inhalers through the pharmacy
• Treat the patient, not a number: consider factors that might impact objective tests such as smoking status, increasing age and height with FeNO, or when reviewing BEC consider if the patient was taking OCS which might impact the result
• Take a steroid history (ICS and OCS) when reviewing control: don’t just consider escalation of therapy but also the potential for related adrenal insufficiency if there is a high steroid burden. Also consider ICS potency; some ICS devices, including extra fine particle devices, have a higher strength
• Always have a follow-up review after a change in therapy: this will ensure there has been no inadvertent disease destabilisation.

Conclusion

Whilst the new guidance is not explicitly SABA-free, it signals a welcome move in that direction. Overall, the update has simplified the approach to diagnosis and management and presents many opportunities for healthcare professionals to work in partnership with patients to improve chronic asthma care.

The new treatment approaches are cost-effective for the NHS and will reduce the number of exacerbations requiring treatment and the number of hospital admissions.

To reduce health inequalities and for uptake of guideline recommendations, concerted implementation programmes factoring behavioural insights, implementation science, theory of change, local population intelligence and educational updates for health staff and patients are useful.

Patients should be signposted to reputable sources of information and their local health providers for further advice and support.

Author

Ravijyot Saggu
Respiratory pharmacist, London, UK, chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE Medicines and Prescribing Associate

References

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