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NICE backs drug over inhalers as step-up treatment for poorly controlled asthma

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Asthma patients should in future be prescribed a leukotriene receptor antagonist as an intermediate step-up between a preventer inhaler and a combination inhaler, if their condition is poorly controlled.

The National Institute for Health and Care Excellence has issued draft guidelines that recommend a major change in current practice for treating asthma patients that it claims could save millions of pounds.

“It is a change that is likely to save the NHS millions each year”

Mark Baker

The proposed guidance, published for public consultation today, said people should be offered an LTRA, which costs 7p per day, earlier than current practice. NICE estimates that £3m a year could be saved for every 10,000 people who take up the new recommendation.

Current practice is to offer people who are newly diagnosed with asthma a reliever inhaler to use whenever they have symptoms. If their asthma is poorly controlled – defined as needing to use a reliever more than three days a week or symptoms keep them awake at night – then they are given a preventer inhaler.

If their asthma continues to be poorly controlled, patients can be offered either an inhaler that combines the preventer medicine with another long-acting medicine or they can take a LTRA.

NICE has now said the LTRA tablet should be offered before the combination inhaler. It said the evidence for combination inhalers and LTRAs showed they were both clinically effective when used as a step-up treatment.

“We now want to hear from all those who provide care for people with asthma”

Mark Baker

But due to its lower price, NICE’s independent guideline committee had concluded that LTRAs were significantly more cost-effective and would be better value for money for the NHS.

If a patient’s asthma remains uncontrolled with LTRAs, then they can add or move to combination inhalers, noted the draft guideline.

It highlighted that children under five should be referred to a specialist if adding an LTRA had not controlled their symptoms.

The guidance will apply to any patient who has poor control on a preventer and needs extra treatment, said NICE. Those already using a combination inhaler will not need to switch if it is working well for them.

Professor Mark Baker, director of the NICE centre for guidelines said: “With this new guideline we want to give clear guidance on how health professionals can help people take control of their symptoms so they can live life to the fullest.

“Millions of people need treatment for their asthma which comes at a price,” he said. “We also need to make sure that we make the best use of NHS resources and our guidance is the first to set out what the most clinical and cost-effective options for treating asthma are.”

Mark Baker

Mark Baker

Mark Baker

Professor Baker added: “We recognise that these new recommendations represent a change to current practice. However, it is a change that is likely to save the NHS millions each year.

“We now want to hear from all those who provide care for people with asthma in the NHS to ensure that the views of those this guidance will affect are fully considered,” he said.

The draft guideline also covers how to help people self-manage their condition. It recommends that people are offered a written plan with details of what triggers their asthma, how to adjust their medicines and when to seek help.

It also sets out when to consider reducing treatment and how health professionals should work with people to make sure they are seen regularly.

The draft guideline is out for public consultation until 16 February.

According to the charity Asthma UK, around 4.5 million people in England are receiving treatment for asthma.

How NICE decided on its new recommendation:

  • NICE’s estiamtions are based on use of the generic leukotriene receptor antagonist montelukast which costs £2.15 for a 28-tab pack. The potential savings for people newly diagnosed with asthma, who needed to be stepped up from inhaled corticosteroids, being prescribed leukotriene receptor antagonists instead of long-acting beta agonists are estimated to be up to £3m per 10,000 people per annum.

Further background information:

  • Reliever inhalers contain a short-acting beta2-agonist. Their peak effect is at 15 minutes which lasts about 4-6 hours.
  • Preventer inhalers contain inhaled steroids, which reduce the inflammation and sensitivity of the airways, and are used once or twice a day.
  • Combination inhalers contain a preventer and a long-acting reliever (long-acting bronchodilator/long-acting beta2-agonist). Long-acting reliever inhalers work in the same way as normal relievers, but their effects can last for up to 12 hours.
  • Leukotriene receptor antagonists (LTRA) are tablets or granules that are taken once a day to stop the airways becoming inflamed.
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