Objective testing, including spirometry and fractional exhaled nitric oxide tests, should be used alongside clinical assessment to help diagnose asthma in primary care, according to new guidance from the National Institute for Health and Care Excellence.
In addition, patients who failed to gain good control with a preventer and were traditionally given a long acting beta-agonist (LABA), should now be offered a leukotriene receptor antagonist (LTRA) tablet with a preventer inhaler before they are given LABA treatment.
“Primary care services should implement what they can of the new guidelines”
However, respiratory experts have claimed that the long-awaited NICE guidance on the diagnosis and monitoring of asthma and the management of chronic asthma could be confusing for clinicians and may lead to a surge in referrals to secondary care.
Work on the new NICE guideline first began work in 2012-13 with draft recommendations published in 2015. The final version was set to be unveiled at the end of October but was delayed again until today.
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The document makes new recommendations on the use of objective testing for asthma – in an effort to cut inappropriate diagnosis and unnecessary treatment – and medicines to manage the condition.
In particular, it seeks to move away from the practice of GPs and nurses routinely trying out different possible treatments in order to work out if someone has asthma or not.
However, the Primary Care Respiratory Society (PCRS) has warned that the document could create uncertainty for primary care clinicians.
This is because it differs in key areas to widely used and respected existing joint guidance on asthma care from the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) – which was updated in 2016 and is endorsed by NICE itself.
One of the two main areas where the guidelines diverge is on the role of and use of different tests to diagnose asthma. The new NICE guideline recommends the use of spirometry, which measures lung function, and fractional exhaled nitric oxide (FeNO) testing for most people with suspected asthma.
FeNO tests measure the concentration of nitric oxide in breath, with increased levels thought to be related to lung inflammation and asthma. But the tests are not widely available in primary care.
“We are concerned at the potential confusion among health professionals”
While the PCRS agreed there was a role for FeNO testing, it said it did not work in all cases and there would be “major implementation challenges” – not least that the higher cost meant it was “unlikely to be a viable option for all practices”.
As a result, the society said this could have “unintended consequences”, including increased referrals to secondary care for asthma diagnosis.
“A perceived mandatory requirement for FeNO and spirometry testing may increase referrals into secondary care,” said the PCRS’s response to the NICE guidance. “This risks de-skilling primary care and overloading secondary care services.”
Meanwhile, it said the new approach meant greater reliance on testing at a single point in time, despite the fact that patients with asthma do not always show symptoms.
Instead, the society recommended the routine use of peak flow monitoring as an initial test for asthma – a test can easily be carried out in GP surgeries and is simple to repeat.
Another key difference in the NICE guidance concerns additional measures to treat people whose asthma cannot be controlled with an inhaler alone.
“We urge the NHS to put guidelines in place as quickly as possible”
At the moment, it is standard practice to offer patients a LABA alongside a low dose inhaled corticosteroid. Patients can get both in the form of a combined inhaler or may be given two separate devices.
However, the NICE guidance now recommends patients are first offered an LTRA tablet alongside their preventer inhaler, as this is considered similarly effective but much cheaper.
The institute has estimated that this change, if widely adopted, could save the NHS an estimated £2m a year for every 10,000 people who go down this treatment route.
The PCRS said it was reasonable to try an LTRA in the first instance in addition to an inhaler, but stressed that it was not appropriate to change the medication of those doing well on a LABA. It warned that clinicians could be confused by the conflicting advice in the NICE and BTS/SIGN documents.
“There is a strong preference in the primary care community for a single comprehensive asthma guideline for the four nations of the UK,” said PCRS policy lead Dr Duncan Keeley.
New NICE asthma guidance ‘clashes’ with established practice
“We are concerned at the potential confusion among health professionals caused by conflicting guideline advice,” highlighted Dr Keeley.
He said: “We identified major potential difficulties in the implementation of the recommendations in the NICE guideline – views shared by many other organisations in the respiratory field – and we advised against its publication.”
He added: “We would encourage NICE and BTS/SIGN to cooperate on a single guideline in future.”
NICE acknowledged changes to diagnostic tests for asthma would take time to implement and involve extra investment and training. But it maintained this would lead to more accurate diagnosis and treatment.
The solution could be to create “diagnostic hubs” locally, which it estimates could save up to £15m over five years, mainly through reducing unnecessary prescriptions.
Professor Mark Baker, director of the centre for guidelines at NICE, said the move to testing with spirometry and FeNO for most people with suspected asthma was “a significant enhancement to practice”.
“The investment and training required to implement the new guidance will take time,” he said. “In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.”
The charity Asthma UK said it welcomed the emphasis on testing before giving people with suspected asthma any form of treatment.
“Currently, doctors who suspect their patients have asthma are encouraged to trial treatment to see if symptoms improve before they diagnose someone,” said Asthma UK chief executive Kay Boycott.
“This is both inefficient and wasteful as around 40% of asthma patients do not respond to initial treatment,” she said. “It could also mean people with asthma are taking medication unnecessarily which could cause side effects.
“These new guidelines make it crystal clear that doctors should be diagnosing patients through objective tests before giving them treatment,” she said. “They will help doctors and nurses feel more confident in their diagnosis and ensure patients are getting the right treatment.
“We urge the NHS to put guidelines in place as quickly as possible,” added Ms Boycott.
The charity also highlighted a need for new, accurate yet low-cost diagnostic tools. Meanwhile, it said all patients with asthma should have an Asthma Action Plan and regular asthma reviews.