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19th February 2025
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.
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.
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 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.
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.
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.
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.
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.
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:
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:
These are some top tips on how to optimise practice in accordance with the guideline recommendations:
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.
Ravijyot Saggu
Respiratory pharmacist, London, UK, chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE Medicines and Prescribing Associate
12th February 2025
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.
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
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 inadequately controlled asthma 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.
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.
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.
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
Additionally, the below considerations may support diagnosis or clinical review, especially where asthma may be uncontrolled; these are important to address before escalating therapy:
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.
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:
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.
Read part 2 of this series, which focuses on the joint guideline recommendations for the pharmacological management of adult chronic asthma.
Ravijyot Saggu
Respiratory pharmacist, London, UK, and chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE Medicines and Prescribing Associate
2nd January 2025
More needs to be done to protect children with asthma in England, including proper implementation of the new UK-wide joint BTS/NICE/SIGN guidelines, Asthma + Lung UK has said.
The charity warned that children from the most deprived areas are four times more likely to die from an asthma attack and called on the Government to take ‘urgent action’ to prevent child asthma deaths, including tackling poor housing conditions and air pollution and ensuring children get the care they need.
This comes as the recent National Child Mortality Database Report on Child Deaths Caused by Asthma shows that between April 2019 and March 2023, 54 children died due to asthma – one every four weeks.
More than half (56%) of the children who died came from the poorest communities.
Well-known risk factors for asthma attacks were common in a high proportion of the deaths, including overuse of reliever inhalers, emergency hospital admissions and exposure to air pollution and cigarette smoke, the report said.
It found 87% of the children had three or more short-acting beta-2 agonist (SABA) inhalers dispensed in the year before their death, with half of them having 12 or more.
In addition, 65% had attended an emergency department or had an emergency admission in the year before death.
All the children who died lived in areas with air pollution above levels recommended by the World Health Organization.
And smoking by family members was recorded in nearly half (43%) of the cases, despite the national average of adults who smoke in the UK being 13%.
Reviews of the deaths documented multiple missed appointments for asthma reviews in primary, secondary and tertiary care over many years, and children being discharged from services.
Poor compliance with preventer medication was also documented, and there were examples of children who were managing their asthma without adult oversight, the report found.
There were also examples of services failing to follow up and escalate appropriately, including SABA inhalers frequently prescribed by GPs despite children not being brought for reviews.
In some cases, healthcare professionals repeatedly referred children to social care due to missed appointments and non-compliance with treatment, stating their concerns about risk of significant harm and death, but this was not followed up.
Asthma + Lung UK said there was a ‘pressing need’ to do more to protect the 1.75 million children in England with the condition and called on the Government to ensure proper implementation of the new UK-wide joint BTS/NICE/SIGN asthma guidelines.
This should include provision of basic care in the community, including accurate diagnosis and annual reviews that include an inhaler technique check and written action plan.
Sarah Sleet, chief executive of Asthma + Lung UK, said: ‘A child dying from asthma every month is devastating and unacceptable.
‘More than a decade after the National Review of Asthma Deaths found that two thirds of asthma deaths are avoidable, people with asthma are still not getting the basic care they need and those living in the most deprived parts of the country are most at risk.
‘Bridging this health gap will only be possible if politicians commit to preventing poor lung health in the first place. This means action to cut smoking rates, tackle air pollution and address issues such as poor housing.’
Dr Andy Whittamore, a GP and clinical lead at Asthma + Lung UK, said: ‘Every week I speak to families who are powerless to change the things making their child’s asthma worse, such as living in damp, mouldy housing, or near busy polluted roads.
‘For children from the poorest communities, their chance of good health is determined almost before they’re born. That has to change.’
He added: ‘The new asthma guidelines offer some hope. Recommendations for better treatments and closer follow-up after a flare-up have the potential to keep children with asthma safe.
‘But without adequate funding and an NHS workforce fully upskilled in asthma care, properly implementing them will be impossible.’
A version of this article was originally published by our sister publication Pulse.
3rd December 2024
The monoclonal antibody benralizumab, which is currently used in the treatment of severe asthma, could help to treat exacerbations in asthma and COPD, according to a new UK trial.
Benralizumab was found to be more effective than a dose of steroids when patients had gone to urgent care clinics or emergency departments with acute symptoms and high eosinophil counts. This reduced the need for further treatment and hospitalisations.
Researchers at King’s College London said the findings could be ‘game-changing’ in an area of medicine that had not changed in 50 years.
In the trial, patients having an asthma or COPD attack were randomly assigned into three groups. The first was treated with a benralizumab injection and placebo tablets, the second received the standard of care of prednisolone 30mg daily for five days plus a placebo injection, and the third received both a benralizumab injection and the standard of care prednisolone.
After 28 days cough, wheeze, breathlessness and sputum were found to be better in patients who had received benralizumab and after 90 days, there were four times fewer people in the benralizumab group that failed treatment compared with those who only received prednisolone.
Writing in The Lancet Respiratory Medicine, the researchers also noted that treatment with benralizumab ‘took longer to fail’, meaning fewer visits to a GP or hospital. There was also an improvement in the quality of life for people with asthma and COPD.
Almost three quarters (74%) of patients who received standard of care prednisolone needed further treatment within 90 days, highlighting the poor outcomes currently seen with short-course steroids when treating eosinophilic exacerbations, they concluded.
The safety profile of benralizumab injections was similar to previous studies and the researchers said it could potentially be given in a GP practice or emergency department.
Eosinophilic exacerbations make up to 30% of COPD flare-ups and almost 50% of asthma attacks, with two million exacerbations of this type in the UK per year.
Study leader Professor Mona Bafadhel, director of the King’s Centre for Lung Health, said: ‘Benralizumab is a safe and effective drug already used to manage severe asthma.
‘We’ve used the drug in a different way – at the point of an exacerbation – to show that it’s more effective than steroid tablets, which is the only treatment currently available.’
She added that the big advancement in this study was discovering that targeted therapy works in asthma and COPD attacks.
‘Instead of giving everyone the same treatment, we found targeting the highest risk patients with very targeted treatment, with the right level of inflammation was much better than guessing what treatment they needed,’ she said.
Dr Samantha Walker, director of research and innovation, at the charity Asthma + Lung UK, said: ‘It’s great news for people with lung conditions that a potential alternative to giving steroid tablets has been found to treat asthma attacks and COPD exacerbations.
‘But it’s appalling that this is the first new treatment for those suffering from asthma and COPD attacks in 50 years, indicating how desperately underfunded lung health research is.’
The publication of this research comes as the long-awaited NICE/BTS/SIGN joint guidelines on management of asthma were launched.
In November, a report revealed that a digital asthma tool could reduce emergency appointments and save NHS £25m annually.
A version of this article was originally published by our sister publication Pulse.
28th November 2024
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‘.
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.
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.’
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.
21st November 2024
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, a report has found.
The digital asthma tool could also help tackle health inequalities, with 54% of users from deprived communities, according to the evaluation by UCLPartners.
The Digital Health Passport (DHP) – an asthma/allergy self-management app designed for teenagers, young adults and the parents/carers of pre-teens – is designed to make it easier for patients to monitor and control their condition.
The evaluation of the digital tool found that the 1,106 users had an average increase of 2.24 points in their Asthma Control Test (ACT) score.
By improving asthma control, the report said DHP could result in fewer out-of-hours and emergency appointments and fewer face-to-face annual reviews.
And the reduced healthcare cost as a result of enhanced asthma control has a potential return on investment of £9.28 for every £1 spent over three years, the report said.
DHP rollout is currently at ‘Level 1’, which means the app links to regional services and resources but is not interoperable with other NHS digital services, such as the NHS app, local shared care records, or individual practice systems.
The app, which has been created by Tiny Medical Apps, focuses on achieving better asthma outcomes by optimising the delivery of the key elements of the asthma care pathway, specifically for children and young people.
This includes making asthma plans smarter with signposting from symptom trackers and improving medication adherence by ordering repeat prescriptions within the app, automated medication reminders, inhaler videos and tracking diaries.
The digital asthma tool also helps patients avoid triggers with air quality alerts and personalised allergy education. And it improves knowledge about asthma by focusing on seven core learning modules and regular reinforcement.
The report also highlighted that TikTok had been particularly effective in engaging young people, demonstrating the importance of targeted digital outreach.
Last month, a report by the Nuffield Trust and Health Foundation revealed that respiratory waiting lists had increased by 263% between May 2014 and May 2024, which is thought to be a consequence of increasing emergency care needs diverting resources away from planned care.
At this year’s European Respiratory Society Congress, a trial showing vocal changes recorded on a smartphone could signal the start of a COPD exacerbation was among the research presented under the Congress’s humans and machines theme.
A version of this article was originally published by our sister publication Healthcare Leader.
6th November 2024
The Royal College of Paediatrics and Child Health’s new ‘landmark’ blueprint is shining a light on what can be done to improve the provision of child health services both on the frontline and with support from the Government. Saša Janković investigates.
Earlier this year, The Academy of Medical Sciences described what it called ‘a crisis in child health’, with the UK ‘failing too many of its children’. And The Children’s Commissioner for England noted that access to children and young people’s healthcare services is a ‘postcode lottery’. Yet while the need for care is rising, the capacity for, and quality of, care is not always keeping up.
NHS Providers points to evidence suggesting children and young people’s services are ‘recovering at a slower rate post Covid-19, in comparison to adult services, impacting on waiting lists and the availability and accessibility of services’.
According to NHS Provider’s ‘Forgotten Generation’ report, in May 2024, 356,200 children and young people were waiting for planned acute care – an increase of 110,000 in just three years. A further 282,000 children and young people were on the community health services waiting list, with 88,900 of this group waiting over 52 weeks.
The latest data for mental health services also paints a concerning picture. The Care Quality Commission’s ‘Monitoring the Mental Health Act in 2022/2023’ report highlights that almost half a million children and young people were waiting for mental health services in November 2023 – a record number that the CQC says had increased by almost 20,000 by January 2024.
The Royal College of Paediatrics and Child Health (RCPCH) has gone further in stating that we are ‘failing a generation of young people’ through a lack of dedicated focus and attention, blaming ‘a decade of chronic underinvestment and lack of national prioritisation in children’s health’.
According to the RCPCH, over three-quarters of respondents to a snapshot poll of its members reported regularly seeing children who have waited over 18 weeks for an appointment, with 83% saying there is not ‘an appropriate level’ of capacity locally to meet demand.
‘The impacts of long waits are as devastating as they are far-reaching,’ says Dr Ronny Cheung, consultant general paediatrician at Evelina London Children’s Hospital, and RCPCH officer for health services. ‘Children and their families are denied child disability payments until seen by a paediatrician. Mild symptoms progressing into much more complicated conditions and a reduced quality of life, school exclusions and wider family stress are impacts that will have life-long consequences and, tragically, are repeated hundreds of thousands of times across the UK.’
In a bid to tackle these issues, the RCPCH’s newly published policy report, entitled ‘From left behind to leading the way: a blueprint for transforming child health services in England’, highlights how the lack of investment in children’s health is having severe consequences. It provides a blueprint which, if taken forward, the Royal College says leaves it ‘hopeful for change’.
The blueprint makes a series of evidence-based recommendations to the new UK Government for change across seven key areas of child health services in funding, workforce, integration, data and digital innovation, urgent and emergency care, community services and primary care. It urges key actions to address the longstanding underinvestment in children’s health services in England built on four national foundations: fair funding, workforce sustainability, improved data systems and prioritisation of children within integrated care systems (ICSs).
Suggestions include developing a child health workforce strategy, introducing a children and young people specific waiting times standard for ICSs, prioritising the development of a digital child health record, and adequately investing in community paediatrics and health visiting and school nursing services.
It also calls for a Children’s Health Investment Standard to address the disparity in funding between adult and child health services and recommends expanding paediatric training posts to ensure a sustainable child health workforce.
One major recommendation in the blueprint is to reduce pressure on urgent and emergency care by embedding paediatric-specific advice and assessment services within NHS 111 – known as Paediatric Clinical Assessment Services. The report says this model has shown significant potential to manage cases earlier, increase self-care rates and reduce emergency department attendances.
Dr Helen Stewart is the RCPCH’s officer for health improvement, as well as a consultant in paediatric emergency medicine at Sheffield Children’s Hospital NHS Foundation Trust, which is one of only three dedicated children’s hospital Trusts in the UK. She says reducing pressure on urgent and emergency care requires properly funded and staffed community services.
‘We get a number of families attending who say they can’t get a GP appointment, and we know primary care is overwhelmed, but there has been a reduction in health visitor numbers as well, so families don’t have anywhere to turn when they are worried and come to the emergency department as a last resort,’ she explains. ‘Then there are young people waiting years for assessments for ADHD across the country and families struggling to access mental health services and so they present to [the emergency department] in crisis.’
A key focus of the RCPCH 2024 blueprint is significant concern around respiratory services, particularly childhood asthma, where the UK has some of the highest emergency admission and death rates in Europe.
To address these issues, the blueprint recommends several key actions, including the expansion of structured asthma care reviews delivered in both primary and secondary care settings, to ensure every child has a personalised asthma action plan and access to specialist support when needed.
Additionally, the report stresses the importance of improving the availability of community-based asthma management services, which can reduce pressure on emergency departments. Another key recommendation is to standardise the approach to early intervention, particularly in schools and community settings, to identify and manage early signs of poorly controlled asthma, thus preventing avoidable flare-ups and hospital visits.
To this end, Amanda Allard, co-chair of the Children and Young People’s Health Policy Influencing Group and director of the Council for Disabled Children, says improvements in information sharing across agencies – for example schools, children’s social care services and the health system – have proven to be ‘essential’ to safeguard children’s health outcomes, wellbeing and safety, but more work needs to be done to optimise this.
‘At the moment, little communication between these services often means not all necessary information is shared about a child who then may not get the care they require,’ she says. ‘More information sharing, as well as using a single child identifier – such as a child’s NHS number – across agencies will significantly improve health outcomes for children and young people, as well as have other positive effects on other aspects of their care and wellbeing. And we also need to improve the quality of the data that we are sharing [otherwise] commissioners don’t have a complete picture of need when they are planning services.’
On the subject of cross-sector integration, Ms Allard adds: ‘We would like to see health professionals working more closely with colleagues in primary care and other agencies such as education and social care to support those colleagues in meeting lower-level needs without the need for referral to secondary care. There are some brilliant examples of this happening such as the Balanced System and Connecting Care for Children. We need these to become universally available.’
NHS Providers is also calling for a cross-government plan to improve the wellbeing of children and young people, with its outgoing CEO Sir Julian Hartley saying that Trusts are ‘ready to play their part in making things better for children and young people’.
But he also stresses that ‘it will require concerted, joined-up working between Trusts, Government, NHS England and local partners including councils, schools and the voluntary sector.’
From Ms Allard’s perspective, ‘the Darzi review acknowledges that “the patient voice is simply not loud enough”, so more must be done to listen to the voices of children, young people and their families, for example by including them in the co-production of guidelines and policies.’
Since most change is reliant on Government funding and top-down approaches, the RCPCH report says if the new UK Government is serious about improving the health of children and young people to raise the healthiest generation of children in our history, then the children’s health workforce needs ‘greater support and changes are needed at a national level to restore and improve health services for children’.
Until there’s movement on this, there are ways in which clinicians and other healthcare professionals in both secondary and primary care can bolster their support for children’s health. According to Dr Stewart, one such way to achieve this is to hone in on ‘the approach that every contact counts’. This, she says, is particularly important as ‘it can be hard for families, especially those in difficult socioeconomic circumstances, to access healthcare – for instance if they are in insecure employment, it’s hard to take a day off work.’
As such, making every contact count can streamline access to healthcare information and make a positive difference to children and their families. ‘If healthcare professionals were able to signpost to relevant services and address other things in their consultations that would be very helpful – such as are vaccinations up to date, healthy eating advice, mental health support – a lot of these only take a very short conversation and some information about where they can access support,’ Dr Stewart says. ‘It can be hard to do when you are really busy but each time we do it, [we] might be helping a family in an important way.’
7th October 2024
Women with asthma are more likely to need fertility treatment to conceive than women without the condition and are also more likely to miscarry, a large Danish study has found.
However, most women with asthma are able to have children, according to the research presented at the European Respiratory Society (ERS) Congress in Vienna, Austria, this month.
Lead author Dr Anne Vejen Hansen, from the department of respiratory medicine at Copenhagen University Hospital, Denmark, said previous research had found women with asthma took longer to become pregnant when undergoing fertility treatment.
Previous research had also showed that women with asthma who succeeded in becoming pregnant were more likely to have used fertility treatment than the general population.
‘But most existing studies focused on women who had become pregnant, so we wanted to examine fertility outcomes on a national scale, to also include those that might not become pregnant at all,’ Dr Vejen Hansen said.
Using a Cox regression model adjusted for age, calendar year and education, the study analysed the reproductive outcomes of all Danish women born between 1976 to 1999 (769,880 women), following them from 1994 to 2017, with a median follow-up of 10.8 years.
Women who repeatedly redeemed anti-asthmatic drugs were classified as having the condition, with asthma severity stratified per 2018 Global Initiative for Asthma (GINA) guidelines.
Overall, 77% of women gave birth over the follow-up period, irrespective of asthma status, the researchers reported.
However, women with asthma experienced a higher degree of foetal loss compared with controls (17.0% vs 15.7%) and used more fertility treatment (5.6% vs 5.0%), researchers reported.
Risk of fertility treatment was significantly higher in women with asthma (HR 1.12), researchers reported.
Furthermore, Dr Vejen Hansen noted women with more severe asthma and those who experienced more flare-ups were especially likely to need fertility treatment.
Women classified as GINA criteria step 4-5 had the highest risk of needing fertility treatment (HR 1.62), while women with three or more prior exacerbations also had an increased risk (HR 1.38).
Dr Vejen Hansen said the drivers behind these associations were unclear, but they could be related to systemic inflammation throughout the body, including women’s reproductive organs.
‘The numbers also show that these same women who redeem asthma medication still have as many live births in the end as women who don’t,’ she said.
‘This suggests that most women with asthma probably do manage to become pregnant and have babies in the end.’
Commenting on the research, Professor Lena Uller, chair of the ERS Airway Pharmacology and Treatment Group, said it was reassuring to see that women seemed to have the same live birth rate regardless of their asthma.
Nevertheless, Professor Uller, who is also head of the Respiratory Immunopharmacology Research Group at Lund University, Sweden, said the study underscored the importance of managing the condition in reproductive-aged women.
‘The fact that the more severe the asthma, the more the problems with fertility, suggests that uncontrolled asthma is the problem and we should be helping women to get their asthma under control,’ Professor Uller said.
Dr Vejen Hansen and colleagues have previously published a large case-control study showing the proportion of women conceiving by fertility treatment was higher among women diagnosed with asthma than in the general population, with the association particularly pronounced among women aged 35 years and older.
The prevalence of fertility treatment preceding live births was 12.2% among women with asthma compared with 7.7% in the control group, with the association remaining significant after adjusting for a range of factors including age, body mass index and smoking status.
When they assessed fertility treatment after stratifying cases and controls into two age-groups (women <35 years and women ≥35 years), no significant association was found between asthma and fertility treatment in the younger age group.
But among women ≥35 years of age, the prevalence of fertility treatment was 24.8% among women with asthma compared with 13.4% in the control group, which also remained statistically significant after adjusting for confounders.
Dr Vejen Hansen and colleagues now plan to conduct a registry-based study to investigate the possible effect of male asthma on fertility.
2nd September 2024
Professor Andy Bush has been at the forefront of paediatric respiratory medicine and research for over three decades. Most recently, he was awarded the Royal College of Paediatrics and Child Health’s highest honour – the James Spence medal – for his outstanding contribution to the field. He spoke to Julie Penfold about his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, and his research into the early origins of asthma.
At the outset of his career in respiratory medicine, Professor Andy Bush initially worked in adult medicine as a trainee chest physician. At the time, he didn’t have any intention of going into paediatrics.
What changed the course of his career was working in a research role in the physiology laboratory led by the late Professor David Denison in the field of pulmonary circulatory physiology. He credits the nearly five years he worked with Professor Denison as being one of his standout career highlights.
‘David Denison was undoubtedly one of the main influences on my career. He was a brilliant respiratory physiologist. At the time, he was collaborating with Dr Elliot Shinebourne who was a great paediatric cardiologist, and I got involved with their research,’ explains Professor Bush.
‘As the research became more and more paediatric, I decided to dip my toe in the water and take on a paediatric job. I went to University College Hospital in London, UK, where I worked as a very junior trainee in the neonatal intensive care unity headed by the legendary Professor Os Reynolds. The job nearly killed me, but it was terrific, and I’ve been in paediatrics ever since.’
Indeed, Professor Bush has been a consultant paediatric chest physician at the Royal Brompton Hospital in London for more than 30 years. He is also professor of paediatrics and paediatric respirology at Imperial College London.
Recently, he was ‘immensely surprised and thrilled’ to learn he had been awarded the Royal College of Paediatrics and Child Health’s (RCPCH) highest honour, the James Spence Medal, for 2024, alongside an honorary fellowship. This highly prestigious medal is awarded by the RCPCH for outstanding contributions to the advancement of knowledge and understanding in paediatrics and child health. But he says it’s an award for his whole team.
‘I had no idea anyone had nominated me for it,’ he says. ‘I’m part of an incredibly brilliant team that also includes nurses, physiotherapists, pharmacists, psychologists and dietitians. If you’re going to look after a child who has a complex condition properly, no one person can do it flying solo.’
Campaigning on public health issues is something that’s very important to Professor Bush. ‘As clinicians, we see the consequences, we read the scientific literature, we see the studies and we can actually produce the evidence,’ he explains. ‘We can and should use this to convince the policy makers that, actually, something needs to be done.’
Professor Bush has had longstanding involvement in a campaign to introduce legislation to stop the advertising and promotion of e-cigarettes to young children, based on a concern that ‘nobody actually knows what they contain’.
He says: ‘There’s a statement that they are 95% safer than cigarettes and it’s based on no evidence whatsoever. What we do know is if you inhale e-cigarettes, you can get an acute lung injury and end up in intensive care.
‘For young people to be inhaling these toxic chemicals into their lungs is really frightening, particularly since there’s evidence of vulnerability. There’s enough animal data to make me really worried about the safety of e-cigarettes. It’s a subject I feel very strongly about.’
In 2024, the UK Government confirmed the marketing, sale and supply of disposable vapes will be banned in the UK from 1 April 2025.
While this is welcome news, Professor Bush feels enforcement is needed to really make the ban work, which is also something a British Medical Association report recently championed.
There are plenty of opportunities to make a difference to children and young people’s health in terms of the range of treatments clinicians in the UK can now offer. However, prohibitive costs for some of these is creating barriers to treatment.
‘Basic science is delivering us the most fantastic new treatments such as the new medications for cystic fibrosis such as Kaftrio, Symkevi and Orkambi. These are absolute game changers as these modulator drugs work by correcting basic defects and making the abnormal proteins work. It’s really fantastic science. But one of the challenges of offering these treatments is the cost as the NHS spends around £1bn annually on them,’ Professor Bush explains.
‘Another example is a promising treatment for the rare condition spinal muscular atrophy. In its most severe form, a baby will never sit up or walk independently, but this now seems to be curable with gene therapy,’ he continues. ‘But a single injection of gene therapy costs the NHS £1.7m. In this country, we are getting a lot of these expensive medications, but across the world, there are places that just simply can’t afford them, so cost is a big challenge.’
Professor Bush’s research interests include the invasive and non-invasive assessment and measurement of airway inflammation in asthma and cystic fibrosis. This includes the use of endobronchial biopsy in the management of severe asthma, and also respiratory mass spectrometry.
He and his team are currently focused on researching the early origins of asthma. ‘There is a lot of evidence that if as a baby you are in an environment of high bacterial diversity, such as on a farm, you are less likely to develop asthma,’ Professor Bush explains.
‘Collaboration with a team led by Professors Saglani and Lloyd at Imperial College has led to beginning to unpick how specific environmental bacteria suppress the development of allergic disease in babies, and the next step after understanding the pathways to allergy and asthma is to design treatments to prevent it – not all babies are going to be brought up on a farm!’
As such, with support from the Wellcome Foundation, his team has recruited a birth cohort of over a thousand mothers and their babies. Samples, such as brushings from the inside of the lung and nose, are taken in the first two weeks of life, analysed for infection and then followed up as they get older.
‘What we’re learning is when you look at a child when they’re first born, those who are going to go on to have asthma will have reduced lung function compared to normal,’ Professor Bush explains. ‘Over the first five or six years of their life, they lose more lung function. They go through a phase of routine viral colds with wheezing and not much in the way of allergy to then developing allergic asthma. But what drives that? If we could find a pathway to stop a child going down the route to develop asthma, it would be such a major thing to do.’
Similar research was undertaken by the Tucson research group in which they followed up 849 of the 1,246 newborn babies who were enrolled in their original children’s respiratory study. They found for some participants the onset of asthma started from their mid-teens to early 20s. Yet this wasn’t a new onset as these individuals had previously experienced asthma symptoms such as wheezing and airway obstruction when they were aged four to six years.
‘What drives those who go into remission and stay in remission is fascinating. If we could switch someone to go into remission who would otherwise go on to have asthma, it would be really exciting,’ Professor Bush adds.
On the horizon, Professor Bush sees more care and monitoring taking place in a patient’s home so regular trips to hospital can be phased out. For conditions such as bronchiolitis, his team is currently looking to find subgroups with particular problems so they can devise a targeted therapy. ‘I also think, increasingly, we will see a move to personalising medicine rather than having a one-size-fits-all approach,’ he says.
Training the next generation of paediatricians is also important to Professor Bush. He has co-supervised more than 50 doctoral students, and more than 100 of his trainees now occupy senior clinical and academic positions.
‘What you really want to do is train people up to be much brighter than you and that, I think I can say without fear of contradiction, I’ve managed to do,’ he says. ‘I’ve been lucky in my career to work some very bright young people who are absolutely soaring ahead in their careers now which is brilliant.’
3rd May 2024
Healthcare professionals prescribing montelukast as an oral add-on therapy for the treatment of asthma in patients aged six months or older should be alert to serious behaviour and neuropsychiatric reactions associated with the treatment, according to a new drug safety update.
This reminder about montelukast from the Medicines and Healthcare products Regulatory Agency (MHRA) comes after continued Yellow Card reports of a range of neuropsychiatric reactions such as sleep disorders, hallucinations, anxiety and depression, and changes in behaviour and mood.
A review of evidence by the MHRA concluded that while the risk of neuropsychiatric reactions with montelukast remains unchanged since its last Drug Safety Update on montelukast in 2019, the Yellow Card reports have indicated this risk is potentially not well known by healthcare professionals, patients and their caregivers.
Commenting on the review, Dr Alison Cave, MHRA chief safety officer, said: ‘Patient safety is our top priority. Throughout our review, we have listened to patient representatives and taken independent clinical advice from paediatricians, specialists in mental and respiratory health and experts from the Commission on Human Medicine’s Expert Advisory Groups.’
She added: ‘We have now taken regulatory action to update the leaflet included in all montelukast medicine packs in the UK with prominent warnings and advice about the risk of serious behaviour and mood-related changes.’
The MHRA is urging healthcare professionals to make patients and their caregivers aware of this information and encourage them to immediately speak to their prescriber or seek urgent medical attention if neuropsychiatric reactions occur while using montelukast.
The regulator also confirmed that the benefits of montelukast continue to outweigh the risks for most patients for the management of asthma and that this is under continuous review.
The risk of neuropsychiatric side effects has been included in the product information for montelukast since 2008, and following a European review in 2019, additional warnings about these risks were included in the EU and UK product information.
Last year, researchers found that prenatal leukotriene receptor antagonist use was not associated with a higher incidence of neuropsychiatric events in their offspring.
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