Key learning points
- Patients should be assessed for their future risk of asthma attacks at every asthma review and their treatment tailored accordingly
- A history of previous asthma attacks should be a warning that a patient is at risk of future asthma attacks
- Adults may be advised to quadruple their normal dose of inhaled corticosteroid at the onset of an asthma attack and for up to 14 days to avoid the use of oral steroids
- Anyone using short acting beta-agonist inhalers frequently has poorly controlled asthma and needs to be identified and assessed urgently in order to improve their treatment
The British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of asthma1 is considered to be the standard upon which to base asthma management in the UK.
The 2019 version introduced a number of changes, including a complete revision of the section on monitoring and updates to sections including supported self-management, non-pharmacological management of asthma, pharmacological management of asthma. This article will focus on these sections but it is important to note that other sections have been updated.
There is a need for regular review for people with asthma to monitor their symptom control and assess the effects that asthma is having on their life. The current BTS/SIGN guideline includes new information on predicting the future risk of asthma attacks, which it recommends should be assessed at every asthma review, on at least an annual basis, to enable targeting of care to those most at risk. The guideline provides a handy checklist of which parameters to include in an asthma review (Table 1).
Table 1. Components of an asthma review
|Current symptom control|
|Future risk of attacks|
Patients should be asked specific questions about their asthma symptoms, such as the Royal College of Physicians ‘3 questions’, and positive responses should prompt further assessment of symptom control with the use of validated questionnaires such as the Asthma Control Questionnaire.
The guidance does not recommend the routine use of fractional exhaled nitric oxide (FeNO) testing (except in specialist asthma clinics) or sputum eosinophilia to monitor asthma.
A history of previous asthma attacks is the greatest indicator that an adult is at risk of future asthma attacks.
Adults with poor symptom control, or who use short acting beta-agonist inhalers (SABAs) inappropriately or excessively, are at moderately increased risk of future asthma attacks.
Factors identified as indicating a slightly increased risk of future attacks in adults are older age, female sex, reduced lung function, obesity, smoking and depression. It may seem surprising that the guideline has not prioritised smoking as having a higher risk here but the Primary Care Respiratory Society (PCRS)2 suggests this may just be a result of poor collection of smoking status.
The greatest risk factors for future asthma attacks in children (aged 5–12 years) are a history of previous asthma attacks and persistent asthma symptoms.
Factors identified as being associated with a moderate risk of future asthma attacks in school-aged children are suboptimal drug regimens, comorbid atopic/allergic disease, low-income family and vitamin D deficiency.
A slightly increased risk of future asthma attacks in this age group is associated with younger age, exposure to environmental tobacco smoke, obesity and low parental education.
Although the guidance found no evidence to indicate an increased risk of asthma attacks in children living in urban areas, since its publication a landmark case has ruled that air pollution contributed to the death of Ella Adoo-Kissi-Debrah, a 9-year-old child with acute asthma who died in 2013 after an asthma attack. Ella lived next to a busy road in London at the time, where nitrogen dioxide levels were found to exceed WHO and European Union guidelines.3 It might therefore be prudent to consider air pollution as a potential risk factor when reviewing children with asthma.
A new recommendation is to consider advising adults to quadruple their normal dose of inhaled corticosteroid (ICS) at the onset of an asthma attack and for up to 14 days to reduce the risk that they will need to take oral steroids.
However, patients who are already highly adherent with their normal medication may not gain so much benefit from this strategy. The guidance recommends that adherence to long-term medication is routinely assessed and suggests some initiatives to promote adherence but acknowledges that such interventions do not clearly improve clinical outcomes.
A systematic review of vitamin D administration in people with asthma found some evidence that vitamin D reduced the risk of severe asthma exacerbation in adults with mild to moderate asthma who were treated with ICSs. More research is needed to find out whether the effect is greater in patients with a lower baseline vitamin D level or what is the optimum dose of vitamin D. While the guidance makes no recommendations about vitamin D, the NHS does advise everyone in the UK to take a daily vitamin D supplement of 10 micrograms (400 IU) between October and early March to support bone, teeth and muscle health.4
Smoking cessation services should continue to be offered to all patients with asthma who smoke, as well as to families and carers of children with asthma to prevent them having exposure to environmental tobacco smoke.
Breathing exercise programmes can be offered alongside pharmacological treatment to reduce symptoms.
It is vital that patients who do not have good asthma control are identified, have their asthma assessed urgently and their treatment improved to reduce their risk of future asthma attacks. The BTS/SIGN guidance advises that anyone who is prescribed more than one SABA in a month has poorly controlled asthma. However, the PCRS has expressed concern that this level of SABA use could indicate very severe asthma that puts patients at increased risk of dying, and recommends a lower threshold of more than six SABAs a year to indicate that a patient is at increased risk of asthma exacerbation.2
Figures 1 and 2 summarise the BTS/SIGN guideline’s updated recommendations for pharmacological management of asthma in adults and children, and provide a handy guide to increasing or decreasing therapies according to the patient’s level of asthma control.
Figure 1. Summary of management in adults
Figure 2. Summary of management in children
ICSs are still recommended as initial regular preventer therapy, and should be titrated to the lowest dose at which effective symptom control is maintained. BTS/SIGN continues to recommend inhaled long acting beta antagonists (LABAs) as initial add-on therapy for adults for whom greater control is needed, which differs from NICE’s advice to add leukotriene receptor antagonists at this step.5
Before stepping up treatment, the patient’s adherence to existing treatment and inhaler technique should always be assessed.
BTS/SIGN suggests that combined maintenance and reliever therapy may be considered as an option for adults with a history of asthma attacks on medium dose ICS or ICS/LABA.
Any patients whose asthma is not adequately controlled with recommended add-on therapy should be referred for specialist care.5
This guidance addresses the environmental impact of metered dose inhalers and advises that greener inhalers be used where possible, and patients should be encouraged to recycle their used inhalers.
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