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Overview

This summary of the All Wales Medicines Strategy Group’s adult asthma management and prescribing guideline encompasses core principles of asthma management, inhaler selection and use, and referral guidance.

View this summary online at guidelines.co.uk/455611.article

Core principles

  • All patients with asthma should be treated with an inhaled corticosteroid (ICS) as the practice of using short-acting bronchodilator (SABA) monotherapy is now outdated and no longer acceptable
  • Review control within a maximum of three months of change in therapy
  • Poor asthma control—use of reliever (including PRN doses of MART regime) >2 times per week, poor symptom control, exacerbations. More than six SABA prescriptions per year should prompt urgent review
  • Review inhaler technique, concordance and co-morbidity at every opportunity including prior to stepping up therapy
  • Consider stepping down treatment if asthma is well controlled
  • Ensure asthma action plan is updated. 

Inhaler principles

  • Choice of inhaler is based on patient’s preference and technique: only choose inhalers that you have observed the patient using correctly
  • If more than one inhaler is being prescribed, both the ICS and SABA inhalers should be of the same type, i.e., do not mix metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) whenever possible
  • Where indicated in Algorithm 1, the MDIs should be inhaled via a spacer device such as an AeroChamber flow-vu
  • Always prescribe by brand to ensure consistent device
  • ICS and long-acting bronchodilators (LABAs) MUST be prescribed as a combination product to obviate the risk of patients inadvertently taking the LABA as monotherapy, which has been associated with increased risk of mortality.

Indications for referral

  • Diagnostic uncertainty
  • Complex comorbidity
  • Suspected occupational asthma
  • Poor control following treatment at step four
  • ≥2 courses of oral steroids/year despite optimising therapy in primary care.

Algorithm 1: Core principles of asthma management and referral

AWMSG asthma algorithm

Copyright 2020, reprinted with permission, All Wales Medicines Strategy Group.

Diagnosis

  • All patients with suspected asthma should undergo objective testing including spirometry/reversibility and peak flow diary monitoring to document evidence of variable airflow obstruction
  • Exhaled nitric oxide (where available) is a simple breath test that can identify eosinophilic airway inflammation. An elevated exhaled nitric oxide level (FeNO) is supportive (but not diagnostic) of asthma
  • It should be usual practice to perform objective testing prior to starting therapy for asthma. If inhalers have already been prescribed, these will need to be withheld prior to performing bronchodilator reversibility testing
  • Most inhaled corticosteroid/long-acting beta2 agonists (ICS/LABAs) will need to be withheld for > 12 hours; however, once daily preparations (e.g. Relvar) will need to be withheld for > 24 hours
  • Short acting beta2 agonists (SABAs) need to be withheld for > 4 hours and long acting anti-muscarinic agents (LAMAs) for > 36 hours
  • Inhalers do not need to be withheld prior to performing FeNO; however, levels of FeNO will be reduced by inhaled corticosteroids. Ideally objective tests should be performed prior to starting inhaled therapy
  • Reversibility to either inhaled or oral corticosteroids could also be considered if initial spirometry is obstructive (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ratio < 0.7 or below lower limit of normal). A change in FEV1 of > 12% and 200 ml confirms reversibility and supports an asthma diagnosis.

Asthma-COPD overlap

  • Some patients with chronic obstructive pulmonary disease (COPD) also show reversibility and asthma and COPD can coexist (asthma-COPD overlap)
  • Clinical history is important in distinguishing asthma from COPD
  • When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:
    • a large (over 400 ml) response to bronchodilators
    • a large (over 400 ml) response to 30 mg oral prednisolone daily for two weeks
    • serial peak flow measurements showing 20% or greater diurnal or day-to-day variability
  • Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy.

Asthma management

Recent guidelines (BTS/SIGN and NICE [diagnosis and monitoring, and chronic asthma management]) have highlighted the need to treat all individuals symptomatic of asthma with inhaled corticosteroids

  • The practice of using a short-acting bronchodilator as monotherapy is outdated and poses dangers, with reports highlighting underuse of inhaled corticosteroids and over reliance on beta-agonists a contributory factor in a number of deaths
  • For individuals with mild, intermittent asthma there is increasing support for the use of inhaled corticosteroid taken together with short-acting bronchodilators on an ‘if and when required’ basis (PRN). This is only recommended for individuals with symptoms less than twice per month
  • If an individual has more frequent symptoms, they should take regular inhaled corticosteroid to reduce their risk of exacerbation and asthma related death.

Asthma control

  • An objective measure of asthma control should be recorded during each consultation. This would usually include a symptom score, such as the ‘asthma control test’ (ACT) or a commonly used tool, the Royal College of Physicians (RCP) ‘three questions’, a measure of airflow obstruction (peak flow or spirometry) and an assessment of exacerbation risk and symptoms based on reliever use and any requirement for oral steroids
  • Reliever inhalers should not be required more than twice per week and the use of more than one reliever inhaler per month reflects very poorly controlled asthma
  • Patients prescribed more than six reliever inhalers over the preceding 12 months should be invited for urgent review of their asthma control.

Table 1: Levels of asthma control and exacerbation risk

Assessment of current clinical control (over last 4 weeks)

Characteristic Completely controlledPartly controlled Uncontrolled

Daytime symptoms more than twice per week

None of these

1-2 of these

 

 

3-4 of these

 

 

Limitation on activities

Nocturnal symptoms/awakening

Need for reliever/rescue treatment more than twice per week

Asthma Control Test

25 20–24 <20

Additional risk factors for future exacerbation

Previous exacerbation/asthma attack

Especially within last 12 months

Intubation/intensive care admission (ever)

Medication concordance

Increased risk if poor ICS adherence (< 80%) and high SABA use (increased risk of mortality if > 1 SABA inhaler/month)

Lung function (peak flow or FEV1)

Increased risk if reduced lung function, especially if < 60% predicted

Comorbidities

Smoking, obesity, gastro-oesophageal reflux disease, pregnancy, chronic rhino-sinusitis, anxiety, depression, confirmed food allergy

Device selection

  • Always involve the patient when choosing the device. Take into account individual preference, ease at which the device can be used and prior success or failure with different preparations.
  • Ensure continuity of device for individual patients so that only one inhaler technique is required. Whenever possible do not mix metered-dose inhalers (MDIs) and dry-powder inhalers (DPIs) as they require radically different inhaler techniques
  • MDIs have a higher carbon footprint than DPI devices and British Thoracic Society guidelines recommend that inhalers with low global-warming potential should be used when they are likely to be equally effective. However, some patients will have a better technique with (and prefer) an MDI device
  • DPIs require inspiratory flow rates of 30–90 l/min. The In-Check DIAL device or training whistles should be used to check patients can achieve this
  • MDIs should be used with a spacer device (Aerochamber flow-vu or Volumatic) to improve technique and lung deposition. The Flo-Tone device is also useful to optimise MDI technique
  • It is important to teach patients that they need to wait 30 seconds between activations of their MDI devices to allow time for the canister to recharge before administering a second dose
  • Inhaled corticosteroids and long-acting bronchodilators MUST be prescribed as a combination product to obviate the risk of patients inadvertently taking the LABA as monotherapy, which has been associated with increased risk of mortality
  • All inhalers should be prescribed by brand to prevent the wrong inhaler device being inadvertently issued by the pharmacy.

Stepping up therapy

  • It is important to check and address factors known to be associated with poor asthma control at every opportunity, including when considering a step up in treatment. The following factors should be considered:
    • inhaler technique
    • adherence with asthma medication. This can be checked by an open conversation with the patient—it is important to be non-judgemental and explore barriers to concordance with medication (e.g. dislike of device, side effects, chaotic lifestyle). The prescription ‘fill rate’ should be reviewed (i.e. the actual number of preventative inhalers collected [issued] in a 12-month period compared with the number that should have been collected [issued])
    • smoking status and referral to smoking cessation services
    • triggers and trigger avoidance (including occupation)
    • co-morbid conditions—e.g. weight management, obstructive sleep apnoea, dysfunctional breathing pattern, rhinitis
  • Asthma control should be re-assessed within three months of a change in therapy.

Maintenance and reliever therapy (MART)

  • A number of combination inhalers are licensed for use in a variable dosing regime termed MART. These include Fostair 100/6 MDI and Nexthaler, Symbicort 200/6 Turbohaler, Fobumix 160/4.5 and Duoresp Spiromax 160/4.5
  • Higher strength preparations are not licensed for this use
  • The patient should take twice-daily maintenance therapy and then also use the same product and device as a reliever medication if required. This enables the amount of inhaled steroid to be titrated against symptoms
  • There is no need to prescribe a separate reliever inhaler if a patient is on this regime
  • MART regimes can help overcome poor concordance with ICS inhalers and historic over reliance on beta2 agonist reliever therapy. There is also evidence these regimes can reduce exacerbation frequency.

For information on licensed MART inhalers and recommendations for daily dosage, refer to the full guideline.

Add-on therapies

  • Step three add-on therapy: montelukast may be particularly helpful in those with exercise-induced asthma and in asthma associated with allergic rhinitis. If patients do not benefit from a six-week trial of this agent it should be discontinued
  • Step three add-on therapy: always treat co-existing allergic rhinitis with a separate nasal steroid +/- antihistamines to prevent asthma triggering from nasal inflammation
  • Step five add-on therapy: Spiriva Respimat (tiotropium) is the only long acting anti-cholinergic licensed for use in asthma. It is recommended within NHS Wales as an option in adult patients who are on maintenance moderate dose ICS/LABA therapy and have experienced one or more severe exacerbations in the previous year. This therapy may be of particular benefit in patients whose asthma and COPD are felt to overlap
  • Step five add-on therapy: oral theophylline is a further add-on therapy that can be trialled at step five. Always review response to add-on therapies and discontinue if ineffective.

Referral/specialist therapy

  • Patients who remain uncontrolled despite moderate dose ICS/LABA +/- additional controller agents have difficult to control or severe asthma. A proportion of these will have an alternative or co-existent condition that is contributing to their symptoms. Objective and structured evaluation can help identify and treat these conditions
  • Some individuals will have severe eosinophilic asthma and will require high-dose ICS/LABA combination inhalers. Others may have neutrophilic asthma and may benefit from additional bronchodilator therapy such as Spiriva Respimat
  • Patients receiving two or more courses of oral steroids in a 12-month period despite concordance with optimised therapy should be referred
  • There are a number of biological therapies licenced for severe asthma. These can be prescribed where appropriate following review by a specialist in severe asthma, and discussion in the All Wales Difficult Asthma MDT.

Stepping down

  • All asthma guidelines recommend a step-wise approach including the need to consider stepping down therapy once control is achieved and maintained
  • High-dose ICS carries a risk of systemic side effects (adrenal suppression, growth retardation, decrease in bone mineral density and cataracts) and these risks should be balanced against the benefits
  • Reductions in asthma therapy should be considered if a patient has had complete asthma control over a three-month period
  • A decision to step down should take into account how difficult it was to achieve stability and also whether previous step-down attempts have resulted in exacerbations
  • Seasonal variation in symptoms should be considered
  • Stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when the medicine was introduced, side effects and the person’s preference
  • It is recommended that the dose of ICS is reduced by no more than 50% each time. The risks and benefits of dose reduction should be discussed with patients and their carers.

Self-management and asthma control

  • Self-management should include a written personalised asthma action plan containing advice on how to recognise a loss of asthma control (peak flow monitoring or symptoms) and what action to take to regain control, including when to start oral steroids and seek emergency advice
  • Patients should be prescribed a peak flow meter to aid self-management
  • Best peak flow should be ascertained when treatment is optimised and symptoms are stable. Best peak flow is more accurate than predicted peak flow. Trigger points should be individualised, but as a guide, oral steroids are usually required when peak flow reaches ≤60% of best and emergency review is usually necessary when peak flow reaches ≤50% of best.

A template for asthma review is available in the full guideline.

For further information on action control, including information on how to achieve a quadrupling in ICS as part of personalised action plan in patients on a fixed-dose combination inhaler, refer to the full guideline.

Full guideline:

All Wales Medicines Strategy Group. All Wales Adult Asthma Management and Prescribing Guideline. AWMSG, 2020. Available at: awmsg.nhs.wales/files/guidelines-and-pils/all-wales-adult-asthma-management-and-prescribing-guidelines-pdf

Published date: August 2020.