The long-awaited UK national joint guidelines for chronic asthma were launched at the 2024 Winter British Thoracic Society meeting. In this first of two articles, Ravijyot Saggu explores the key updates and implications of the new guidelines for practice, including diagnosis and monitoring, with a focus on chronic asthma in adults.
Previous iterations of asthma guidelines have been produced either by the National Institute for Health and Care Excellence (NICE) or the British Thoracic Society (BTS) in conjunction with the Scottish Intercollegiate Guidelines Network (SIGN), but these have sometimes conflicted, confusing their application in practice.
Earlier guidance has steered practitioners towards initial treatment of asthma or suspected asthma and infrequent wheeze, with short-acting beta-agonists (SABA) – usually salbutamol. These have traditionally been called ‘reliever’ inhalers, reinforcing the patient associating ‘relief’ with using SABA and inadvertently encouraging SABA reliance rather than inhaled corticosteroid (ICS) use as the mainstay of treatment.
For the first time, the NICE, BTS and SIGN have come together to produce one unified guideline and initiate a move away from SABA-only prescribing. This ensures consistent messaging and a change in treatment approach.1
The joint guideline is evidence-based and considers cost-utility analysis. It was developed with an expert committee and broad stakeholder consultation at the draft stage and is intended for use in patients with suspected or already diagnosed asthma.
The scope of the joint guideline was restricted to the diagnosis, monitoring and treatment of chronic asthma. Therefore, other areas, such as acute or severe asthma, have not been updated in this iteration.
Why was the joint chronic asthma guideline needed?
Asthma care is still suboptimal in children and young people, leading to avoidable harm and mortality, with roughly one related death every four weeks. A recent national report on deaths of children and young people from asthma and anaphylaxis has highlighted key contributory themes and recommendations for action to prevent future asthma-related harm.2
Similarly, the National Review of Asthma Deaths (NRAD) 2014 report highlighted failures of basic asthma care.3 Sadly, many of the deaths reviewed were deemed to have been preventable.3
NRAD identified SABA overuse as one of the contributory factors to these preventable deaths. Some 39% were prescribed more than 12 SABA inhalers in the year before they died, while 4% had been prescribed more than 50 reliever inhalers. Those prescribed more than 12 reliever inhalers were likely to have had poorly controlled asthma.
There was also evidence of under-prescribing of preventer medication and inappropriate prescribing of long-acting beta-agonist (LABA) bronchodilator inhalers, including LABA monotherapy without ICS preventer treatment.3 LABA monotherapy is not recommended for the treatment of asthma.
Since NRAD, there has been more focus on SABA overprescribing as a flag for uncontrolled disease, with thresholds ranging from three to six SABA inhaler prescriptions per year as a marker of overprescribing, underutilisation of ICS and poorer asthma control.4,5
Despite the NRAD report findings, we still have poor asthma-related mortality and outcomes in the UK over 10 years later. An all-party parliamentary group (APPG) report in 2020 highlighted that asthma attacks in the UK had increased by a third in the decade prior.6
It is widely known that incidence and mortality of respiratory disease are generally higher in disadvantaged groups and areas of social deprivation. Asthma attacks kill three people in the UK each day – the highest level in Europe – and every 10 seconds someone has a potentially life-threatening asthma attack.7
Uncontrolled asthma
Although some patients may perceive asthma as a cyclical condition, it is a chronic, inflammatory condition that can be well managed with the correct treatment and adherence. While SABA provide temporary bronchodilation, they do not target airway inflammation,6 which requires ICS.
ICS are an effective, evidence-based and largely well-tolerated part of asthma management.
Asthma may be uncontrolled for various reasons, such as non-adherence, undertreatment or a specific type of inflammation that requires specialist review and investigation, and, in some cases, potentially treatment with biologics. To address poor control, the correctable factors should be modified and optimised, including consideration of additional diagnoses and optimal comorbidity management.
A useful pathway for recognising and optimising adequately controlled asthma and optimising has been developed. It can be used in any setting to focus patient care promptly and ensure that the fundamentals are addressed early before appropriate referral to specialist care.
Uncontrolled asthma can lead to exacerbations and may result in hospital admission or emergency department attendance and an increased utilisation of health resources.
Some exacerbations may be severe or life-threatening, and it is essential to be able to recognise and assess signs of severe and life-threatening asthma, including exhaustion, cyanosis, inability to complete sentences in one breath, altered consciousness and reduced peak expiratory flow.
It is important that exacerbations are prevented and asthma control well managed. Management usually involves temporary increased SABA use, a short course of oral corticosteroids (OCS) and often accompanying antibiotics if a bacterial infection is suspected.
Additionally, it is prudent to limit the cumulative OCS and antimicrobial exposure that ensues with exacerbations to minimise side effects and antimicrobial resistance.
Issues with steroid use
There is often a negative association of steroids being harmful, which may be a factor in patient non-adherence to therapy.7,8
ICS differ from OCS, but limiting the overall steroid burden, especially for OCS, and avoiding secondary adrenal insufficiency is important.
Many of the commonly known side effects associated with steroids, such as weight gain, osteoporosis and diabetes are related to OCS and their longer-term or repeated use, reiterating the importance of good disease control to prevent exacerbations.
Side effects with ICS are more local in comparison. They can be minimised by the correct inhaler technique and using an inhaler device best matched to the person’s inhalation ability, which includes using a spacer with a metered dose inhaler where appropriate.
Key guideline changes for chronic asthma
It is important to be able to rule asthma in or out, using objective tests supported by a good clinical history and considering alternative and additional diagnoses. Key updates have been made to the diagnosis and monitoring of asthma in the new joint guideline and are discussed below.
- Diagnosis
There is no gold standard test to diagnose asthma. In adults aged 16 years and above, the new guidance recommends sequential use of the following tests to confirm a diagnosis of asthma:1
- Initially check for the presence of raised blood eosinophil counts or fraction of exhaled nitric oxide (FeNO) levels, if available, to make a diagnosis
- If available, this can further be confirmed by bronchodilator reversibility (BDR) with spirometry and salbutamol
- If spirometry is unavailable or delayed, peak expiratory flow (PEF) should be measured twice daily for two weeks
- If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but is still suspected on clinical grounds, the patient should be referred to secondary care for consideration of a bronchial challenge. An asthma diagnosis is given if bronchial hyperresponsiveness is present.
Additionally, the below considerations may support diagnosis or clinical review, especially where asthma may be uncontrolled; these are important to address before escalating therapy:
- Occupational exposure, such as dust from chemicals or food (for example, woodwork, building work, breadmaking – although these are not exhaustive)
- Domestic exposure, such as pets or cold and damp living conditions where mould may be present
- Smoking, including passive indoor exposure
- Seasonal or psychosocial factors, such as stress and anxiety
- Presence of upper airways involvement, specifically the nose.1
Please note that diagnosis is slightly different for children aged five to 16 years and this is outside the scope of this article, but see the algorithm for further information.
- Monitoring
A key change in the new guidance is a move away from what is traditionally associated with monitoring asthma. Routine monitoring of PEF is now not recommended, although a small cohort of patients may still require this. A validated symptom questionnaire such as the Asthma Control Test can be considered at asthma-related reviews such as annual reviews.
Patient perceptions of disease severity, control and risk may not correlate with clinical state.3,9 It is important to explore the patient’s perceptions and the results of validated questionnaires, as they may contradict each other.7 Perceptions and illness beliefs also impact treatment adherence.
As FeNO is an indicator of airway inflammation, the joint guidelines suggest considering the measurement of FeNO at review, as well as before or after changing pharmacological therapy.
This may also be useful to support patient discussions on the level of disease control, in particular where their perception of it contrasts with the objective test, although various factors can impact FeNO levels.
As with diagnosis, a structured clinical history is vital to elicit the relevant information about symptoms, disease control and triggers. At patient review, ask about the following:
- Time off work or school due to asthma
- Amount of reliever use, including a check of prescription record
- The number of courses of OCS over the last six to 12 months
- Any admissions to hospital or emergency department attendance due to asthma.1
Conclusions
The new joint guidelines herald a radical change in diagnosis, treatment and monitoring and have been welcomed as a much-needed improvement in chronic asthma care. They represent a move to a more straightforward pathway and offer a new and pragmatic approach to implementation.
Part 2 of this series will focus on the joint guideline recommendations for the pharmacological management of adult chronic asthma.
Author
Ravijyot Saggu
Respiratory pharmacist, London, UK, and chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE Medicines and Prescribing Associate
References
- National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). NICE guideline NG245 [Accessed February 2025].
- National Child Mortality Database. Child deaths due to Asthma or Anaphylaxis. [Accessed February 2025].
- Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). [Accessed February 2025].
- Janson C et al. An Overview of Short Acting B2 Agonist Use in Asthma in European Countries. Adv Ther 2020;37(3):1124–35.
- De Simoni A et al. Reducing SABA overprescribing in asthma: lessons from a Quality Improvement prescribing project in East London. Br J Gen Pract 2022;72(722):e619–e626.
- All Party Parliamentary Group for Respiratory Health. APPG Report. Improving Asthma Outcomes In the UK. One Year On. [Accessed February 2025].
- NHS RightCare. RightCare asthma scenario. [Accessed February 2025].
- General Pharmaceutical Council. Patient safety spotlight: the risks of overprescribing Salbutamol inhalers for asthma. [Accessed February 2025].
- Bidad N, Barnes N, Griffiths C. Understanding patients’ perceptions of asthma control: a qualitative study. Eur Res J 2018;51(6):1701346.
- Chan AHY et al. Medication beliefs, adherence, and outcomes in people with asthma: The importance of treatment beliefs in understanding inhaled corticosteroid nonadherence – a retrospective analysis of a real-world data set. J Allergy Clin Immunol Global 2023;2(1):51–60.
- Rabe K et al. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality survey. J Allergy Clin Immunol 2004;114:40–7.
