General principles of pharmacological treatment

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.

Licensed indications for asthma inhalers vary between different medicines, different doses and different devices. Not all asthma inhalers are licensed for use in line with the recommendations in this guideline. See NICE's information on prescribing medicines and refer to the summary of product characteristics for individual products.

 

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1.6.1 Take into account and try to address the possible reasons for uncontrolled asthma before starting or adjusting medicines for asthma in adults, young people and children. These may include:

  • alternative diagnoses or comorbidities
  • suboptimal adherence (see the recommendation on adherence)
  • suboptimal inhaler technique
  • smoking (active or passive), including vaping using e-cigarettes
  • occupational exposures (see the recommendation on checking for possible occupational asthma)
  • psychosocial factors (for example, anxiety and depression, relationships and social networks)
  • seasonal factors
  • environmental factors (for example, air pollution, indoor mould exposure).

[NICE 2017, BTS/SIGN 2019, amended 2024]

 

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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).

[BTS/NICE/SIGN 2024]

 

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

[BTS/NICE/SIGN 2024]

 

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1.6.4 After starting or adjusting medicines for asthma, review the response to treatment in 8 to 12 weeks (see the recommendations on monitoring asthma control).

[NICE 2017, amended BTS/NICE/SIGN 2024]

 

              

Rationale and impact

Why the committee made the recommendations

The evidence review showed that clinical outcomes were poorest in all age groups with asthma when using SABA (short-acting beta2 agonist) alone. The committee also took into account other evidence from several sources, including national reviews of asthma deaths in both adults and children, which highlighted the dangers of using SABA without ICS in people with asthma. They therefore recommended that SABA alone should not be used in people with a diagnosis of asthma.

The previous NICE and BTS/SIGN guidelines had recommended a number of actions which should be taken before increasing treatment, and the committee agreed by consensus that a FeNO check should also be done as long as the equipment is available to do this.

How the recommendations might affect practice

The prescription of SABA alone has been commonplace, although this is becoming less so because of the publicity around asthma deaths. The recommendation will reduce its use further. The replacement therapies in adults and children are more expensive, but they should produce clinical benefits and cost savings through a reduction in exacerbations.

 

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