Long-awaited joint UK guidelines for asthma have been finalised, overhauling recommendations for diagnostics and treatment of the condition.

In June, draft guidance published by NICE, BTS and SIGN revealed significant changes to the current treatment approaches, including replacing the use of short-acting beta agonist (SABA) alone with combined inhaled corticosteroid (ICS)/formoterol inhalers.

The final guidance 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 the use of 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’.

NICE has emphasised that health professionals should ‘always prescribe maintenance or combination treatments’ rather than the ‘familiar blue “reliever-only” inhaler, when asthma is first diagnosed’.

This is the first time NICE has produced joint UK-wide guidance on the diagnosis and management of chronic asthma for adults, young people and children.

It is based on evidence which ‘showed that using the combined ICS and formoterol inhalers when required led to people suffering fewer severe asthma attacks’.

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.

Asthma and Lung UK clinical lead Dr Andy Whittamore, who is also a GP, 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 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.’

A version of this article first appeared on our sister site Pulse.

New joint asthma guidance in full

Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)

Testing – adults

1.2.1 Measure the blood eosinophil count or fractional exhaled nitric oxide (FeNO) level in adults with a history suggestive of asthma. Diagnose asthma if the eosinophil count is above the laboratory reference range or the FeNO level is 50 ppb or more.

1.2.2 If asthma is not confirmed by eosinophil count or FeNO level, measure bronchodilator reversibility (BDR) with spirometry. Diagnose asthma if the FEV1 increase is 12% or more and 200 ml or more from the pre-bronchodilator measurement (or if the FEV1 increase is 10% or more of the predicted normal FEV1).

1.2.3 If spirometry is not available or it is delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.

1.2.4 If asthma is not confirmed by eosinophil count, FeNO, BDR or PEF variability but still suspected on clinical grounds, refer for consideration of a bronchial challenge test. Diagnose asthma if bronchial hyper-responsiveness is present.

Children aged 5 to 16

1.2.5 Measure the FeNO level in children with a history suggestive of asthma. Diagnose asthma if the FeNO level is 35 ppb or more.

1.2.6 If the FeNO level is not raised, or if FeNO testing is not available, measure BDR with spirometry. Diagnose asthma if the FEV1 increase is 12% or more from baseline (or if the FEV1 increase is 10% or more of the predicted normal FEV1).

1.2.7 If spirometry is not available or it is delayed, measure PEF twice daily for 2 weeks. Diagnose asthma if PEF variability (expressed as amplitude percentage mean) is 20% or more.

1.2.8 If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds, either perform skin prick testing to house dust mite or measure total IgE level and blood eosinophil count.

    • Exclude asthma if there is no evidence of sensitisation to house dust mite on skin prick testing or if the total serum IgE is not raised.
    • Diagnose asthma if there is evidence of sensitisation or a raised total IgE level and the eosinophil count is more than 0.5 x 109 per litre.

1.2.9 If there is still doubt about the diagnosis, refer to a paediatric specialist for a second opinion, including consideration of a bronchial challenge test.

Monitoring asthma control

1.5.1 Monitor asthma control at every review. In addition to asking about symptoms, check:

    • time off work or school due to asthma
    • amount of reliever inhaler used, including a check of the prescription record
    • number of courses of oral corticosteroids
    • any admissions to hospital or attendance at an emergency department due to asthma.

1.5.2 Consider using a validated symptom questionnaire (for example, the Asthma Control Questionnaire, the Asthma Control Test or the Childhood Asthma Control Test) at any asthma review.

1.5.3 Do not use regular peak expiratory flow (PEF) monitoring to assess asthma control unless there are person-specific reasons for doing so (for example, when PEF measurement is part of the personalised asthma action plan).

1.5.4 Consider fractional exhaled nitric oxide (FeNO) monitoring for adults with asthma:

    • at their regular review, and
    • before and after changing their asthma therapy.

Pharmacological treatment

1.6.2 If possible, check the fractional exhaled nitric oxide (FeNO) level when asthma is uncontrolled. If it is raised this may indicate poor adherence to treatment or the need for an increased dose of inhaled corticosteroid (ICS).

1.6.3 Do not prescribe short-acting beta2 agonists to people of any age with asthma without a concomitant prescription of an ICS.

1.6.10 Digital inhalers are not recommended for routine use in people with asthma.

People aged 12 and over

1.7.1 Offer a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief (as-needed AIR therapy) to people aged 12 and over with newly diagnosed asthma.

1.7.2 If the person needing asthma treatment presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation, start treatment with low-dose MART (maintenance and reliever therapy) in addition to treating the acute symptoms as indicated (that is, a course of oral corticosteroids may be needed). Consider stepping down to as-needed AIR therapy using a low-dose ICS/formoterol inhaler at a later date if their asthma is controlled.

Medicine combination and sequencing in people aged 12 and over

1.7.3 Offer low-dose MART to people aged 12 and over with asthma that is not controlled on a low-dose ICS/formoterol combination inhaler used only as needed.

1.7.4 Offer moderate-dose MART to people aged 12 and over with asthma that is not controlled on low-dose MART.

1.7.5 For people aged 12 and over with asthma that is not controlled on moderate-dose MART despite good adherence:

  • Check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count. If either of these is raised, refer to a specialist in asthma care.
  • If neither FeNO or eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART. Give the medicine for a trial period of 8 to 12 weeks unless there are side effects. At the end of the trial:
    • if asthma is controlled, continue the treatment
    • if control has improved but is still inadequate, continue the treatment and start a trial of the other medicine (LTRA or LAMA)
    • if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA).

1.7.6 Refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA.

Transferring people aged 12 and over from pathways previously recommended by NICE

1.7.7 Change treatment for people with confirmed asthma who are currently using a short-acting beta2 agonist (SABA) only to a low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy).

1.7.8 Consider changing treatment to low-dose MART for people with asthma that is not controlled on:

  • regular low-dose ICS plus SABA as needed
  • regular low-dose ICS/LABA (long-acting beta2 agonist) combination inhaler plus SABA as needed
  • regular low-dose ICS and supplementary therapy (LTRA) plus SABA as needed.
  • regular low-dose ICS/LABA combination inhaler and supplementary therapy (LTRA) plus SABA as needed.

1.7.9 Consider changing treatment to moderate-dose MART for people with asthma that is not controlled on:

  • regular moderate-dose ICS plus SABA as needed
  • regular moderate-dose ICS/LABA combination inhaler plus SABA as needed
  • regular moderate-dose ICS and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed
  • regular moderate-dose ICS/LABA combination inhaler and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed.

1.7.10 When changing from low- or moderate-dose ICS (or ICS/LABA combination inhaler) plus supplementary therapy to MART, consider whether to stop or continue the supplementary therapy based on the degree of benefit achieved when first introduced.

1.7.11 Refer people with asthma that is not controlled on treatment containing a high dose of ICS to a specialist in asthma care.

Risk-stratified care 

1.15.1 Consider actively identifying people with asthma who are at risk of poor outcomes and tailor care to their needs. Risk factors should include:

  • non-adherence to medicines
  • over-use of short-acting beta2 agonist (SABA) inhalers (more than 2 inhalers per year)
  • needing 2 or more courses of oral corticosteroids per year
  • 2 or more visits to an emergency department or any hospital admission for asthma.

Source: NICE