Transferring people aged 12 and over from other treatment pathways

Asthma pathway (BTS, NICE, SIGN) [SIGN 244]

This content is from the BTS, NICE and SIGN guideline - Asthma: diagnosis, monitoring and chronic asthma management (SIGN 245), 2024.

These recommendations are for people with uncontrolled asthma who are on the treatment pathway recommended by previous NICE and BTS/SIGN guidelines.

 

R

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).

[BTS/NICE/SIGN 2024]

 

R

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.

[BTS/NICE/SIGN 2024]

 

R

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.

[BTS/NICE/SIGN 2024]

 

R

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.

[BTS/NICE/SIGN 2024]

 

R

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.

[BTS/NICE/SIGN 2024]

 

           

Rationale and impact

Why the committee made the recommendation

The treatment pathway recommended in this guideline update for people aged 12 and over relies on using MART with increasing dose of regular ICS/formoterol, depending on response to treatment. This is a different strategy from that recommended by previous guidelines (NICE and BTS/SIGN) and many people will be on treatment that is not part of this new pathway. The committee recognised that this will cause a problem for these people when their asthma is not controlled. They therefore discussed and agreed how treatment should be changed in these circumstances. They noted that the general advice about checking inhaler technique, adherence, etc. (see the first recommendation in the section on principles of pharmacological treatment) before escalating treatment still applies here. The recommendations are not based on a specific evidence search, but the committee noted that people in the MART studies reviewed for recommendations 1.7.3 to 1.7.6 (see the section on medicine combination and sequencing in people aged 12 and over) were taking some form of non-MART therapy before study entry and that the improvement shown in comparison to both baseline and to the control treatments support the switch to MART.

How the recommendation might affect practice

The recommendations will result in more people being switched to MART than to other treatment options, but MART is used at present, and the change should not be disruptive.

 

Full details of the evidence and the committee’s discussion are in evidence review P: drug classes for initial asthma management and evidence review Q: drug combinations and sequencing for asthma management.