Clinicians should assess all asthma patients for their future asthma attack risk and personalise their treatment and care, recommends updated joint guidance* from the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN).
Every asthma review should involve an assessment, including various breathing tests and investigations, not only of current asthma control, but of the key factors that put a person at greatly increased risk of a future attack, it says. These are history of previous asthma attacks; poor current control of their asthma; and overuse of reliever medication.
Clinicians are also advised to be aware of factors that can “moderately” or “slightly” increase risk.
Several factors heighten a child’s risk of future asthma attacks, says the guidance. These include an existing allergy; younger age; obesity; and exposure to environmental tobacco smoke.
Among adults, older age, female gender, reduced lung function, obesity, smoking and depression are markers of a slightly increased risk of future asthma attacks.
The guideline emphasises the importance of asthma reviews at least annually to assess future asthma attack risk, current symptoms, and treatment, with growth also checked in children.
The guidance doesn’t recommend routine use of FeNO testing except in specialist asthma clinics. The test involves measuring an individual’s fractional exhaled nitric oxide, which is slightly higher in people with asthma.
An increase may suggest some inflammation of the airways but doesn’t prove a diagnosis of asthma, says the guidance.
Nor does it recommend routine use of a sputum eosinophilia test to assess “biomarkers” of inflammation in a patient’s spit to monitor asthma.
The guidance encourages NHS policy makers to address current inequalities in asthma outcomes by developing proactive plans to reach people with uncontrolled asthma, who may be vulnerable or from poorer backgrounds, and include help to quit smoking and reduce exposure to environmental tobacco smoke.
In asthma action plans for adults, clinicians are advised to consider quadrupling the level of the key inhaled preventer medication at the onset of an asthma attack, and if necessary for up to 14 days afterwards, to stop it in its tracks and avoid the need for ongoing oral steroids.
But clinicians need to weigh up the pros and cons of the strategy in people already on high dose inhaled corticosteroids, especially if they are experiencing frequent asthma attacks, says the guidance.
And if asthma symptoms are still problematic after the use of an inhaled corticosteroid, the next “add on” treatment recommended is an inhaled long-acting beta agonist (LABA).
If this doesn’t work, then the guidance recommends increasing the dose of inhaled corticosteroid from low to medium dose in adults or from very low to low dose in children (5–12 years).
At this stage clinicians can also consider prescribing a leukotriene receptor antagonist as an “add on” treatment. This comes in tablet form.
The option of combined maintenance and reliever therapy (MART) in adults with a history of asthma attacks on medium dose inhaled corticosteroids, or in combination with LABA, should be considered. MART may be easier for some patients as they don’t need to use an additional reliever inhaler for persistent symptoms.
In a few patients, asthma is not adequately managed using standard controller therapies. New therapies are becoming available that reduce the frequency of asthma attacks, but their administration is complex and requires specialist input.
The guideline therefore recommends that all such patients should be referred for specialist care.
The guidance also covers non-drug treatment and says that breathing exercises, led by a physiotherapist or using audio-visual programmes, can be offered to adults in addition to medication to help improve quality of life and reduce symptoms.
Dr John White, BTS member and consultant respiratory physician at York NHS Foundation Trust, co-chaired the group that produced the updated guidance.
“At the heart of the new guideline is a drive towards providing more tailored and personalised care to help people manage their asthma effectively and reduce acute illness from the condition,” he said.
“The advice on how to predict an individual’s future asthma attack risk will support the NHS to identify those most likely to face potentially life-threatening attacks and deliver specific strategies to prevent this.”
Some 5.4 million people are currently being treated for the condition in UK at an annual cost to the NHS of £1 billion.
*Guidance also available here