Asthma: management in adults

Asthma: management in adults

In 2024 NICE, the British Thoracic Society and SIGN produced joint guidelines on the management of asthma following many years of conflicting guidelines. The new guidelines represent a major step change in the management of asthma is both diagnosed and treated.

For many years patients with asthma were started on a short-acting beta-2 agonist (SABA) inhaler before 'stepping up' to a regular inhaled corticosteroid with a SABA as required. The new guidelines now advocate the use of combined inhalers (ICS + long-acting beta-2 agonist) as reliever therapy or regularly, depending on the severity of asthma. Given the prevalence of asthma, it is likely that doctors will have to deal with patients on 'conventional' asthma treatments for many years to come. The joint guidelines therefore include guidance on how to manage these patients if their current treatment is controlling their symptoms sufficiently.

Management of adult patients aged children aged ≥ 12 years with newly diagnosed asthma

Step 1 NICE

• a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
  Asthma: adults and children ≥ 12 years first-line treatment --> low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as required
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  Importance: 74
  • this is termed anti-inflammatory reliever (AIR) therapy
• if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
  • start treatment with low-dose MART
    start treatment with low-dose MART
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    (maintenance and reliever therapy, see below)
  • treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)

Step 2 NICE

• a low-dose MART
  Asthma: adults and children ≥ 12 years second-line treatment --> low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler regularly and as required (MART)
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  Importance: 39
  • MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required

Step 3

• a moderate-dose MART
  Asthma: adults and children ≥ 12 years not controlled on low-dose MART --> moderate-dose MART
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  Importance: 15

Step 4

• check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count
  Asthma: adults not controlled on moderate-dose MART --> check the FeNO level if available, and the blood eosinophil count
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  Importance: 35
  NICE
  • if either of these is raised, refer to a specialist in asthma care
    Asthma: adults not controlled on moderate-dose MART - if either FeNO level or blood eosinophil raised then --> refer to a respiratory specialist
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    Importance: 24
  • if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA)
    Asthma: adults not controlled on moderate-dose MART - if neither FeNO level nor blood eosinophil raised --> trial of either a LTRA or a LAMA
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    Importance: 21
    used in addition to moderate-dose MART
  • if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)

Step 5

• refer people to a specialist in asthma care
  Refer adults to a respiratory specialist when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA
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  Importance: 28
  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 other treatment pathways

There will be many people whose asthma was managed according to the previous guidelines that present with uncontrolled asthmatic symptoms. The guidelines give advice on how these people should be switched: NICE

+PassMedicine Notes

In 2024 NICE, the British Thoracic Society and SIGN produced joint guidelines on the management of asthma following many years of conflicting guidelines. The new guidelines represent a major step change in the management of asthma is both diagnosed and treated.

For many years patients with asthma were started on a short-acting beta-2 agonist (SABA) inhaler before 'stepping up' to a regular inhaled corticosteroid with a SABA as required. The new guidelines now advocate the use of combined inhalers (ICS + long-acting beta-2 agonist) as reliever therapy or regularly, depending on the severity of asthma. Given the prevalence of asthma, it is likely that doctors will have to deal with patients on 'conventional' asthma treatments for many years to come. The joint guidelines therefore include guidance on how to manage these patients if their current treatment is controlling their symptoms sufficiently.

Management of adult patients aged children aged ≥ 12 years with newly diagnosed asthma

Step 1 NICE

• a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
• this is termed anti-inflammatory reliever (AIR) therapy
• if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
• start treatment with low-dose MART (maintenance and reliever therapy, see below)
• treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)

Step 2 NICE

• a low-dose MART
• MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required

Step 3

• a moderate-dose MART

Step 4

• check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE
• if either of these is raised, refer to a specialist in asthma care
• if neither FeNO nor 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
• if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)

Step 5

• 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 other treatment pathways

There will be many people whose asthma was managed according to the previous guidelines that present with uncontrolled asthmatic symptoms. The guidelines give advice on how these people should be switched: NICE

Existing asthma treatment _ New asthma treatment| SABA as required only _ Low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy)| SABA as required + regular low-dose ICS SABA as required + regular low-dose ICS/LABA SABA as required + regular low-dose ICS + LTRA SABA as required + regular low-dose ICS/LABA + LTRA _ Regular low-dose regular ICS/formoterol combination inhaler (MART therapy)| SABA as required + regular moderate-dose ICS SABA as required + regular moderate-dose ICS/LABA SABA as required + regular moderate-dose ICS + LTRA or LAMA SABA as required + regular moderate-dose ICS/LABA + LTRA or LAMA _ Regular moderate-dose MART therapy| Treatment regime containing a high-dose ICS _ Refer to a respiratory specialist|