respiratory
Asthma

Asthma guideline double up ‘confusing’ and potentially ‘harmful’


The decision by the National Institute of Clinical excellence (NICE) to go ahead with its asthma guidelines has been slated by respiratory health professionals who say they will lead to confusion and have the potential to compromise patient care.

Speakers at the British Thoracic Society’s (BTS) Winter Meeting in London this week said the guidelines differed markedly from BTS/SIGN guidelines and had created a “ridiculous” situation that could ultimately harm patient care.

“This is not a helpful position to be in. There isn’t a resolution. NICE has gone ahead. We said we didn’t think it was sensible to have another guideline,” Dr James Paton, BTS/SIGN guideline development group member, told delegates attending a session on the next iteration of the BTS asthma guidelines.

See Related Story: BTS/SIGN asthma guidelines: the next generation

He predicted that doctors would “pick and choose” which recommendations to follow from each set of guidelines. “I don’t think that’s going to be helpful for patients,” he said.

In a separate session, Stephen Fowler, lecturer at the University of Manchester, said a fundamental difference between the guidelines was a “philosophical” difference in approach to asthma diagnosis.

The NICE guidelines say doctors should not diagnose asthma on symptoms alone, but should use at least one “objective test” for diagnosis.

The guideline proposes use of fractional exhaled nitric oxide (FeNO), spirometry or peak flow variability. Whereas the current BTS guidelines recommend an initial clinical assessment, followed by a six-week treatment trial for those with probable asthma, with tests used in cases of diagnostic uncertainty or to confirm diagnosis after a successful treatment trial.

The NICE algorithm for diagnostic tests “has not been validated,” said Dr Fowler, and the proposal that everyone 17 or over should be offered a FeNO test “would be difficult”, he told delegates.

He also criticised the “hard cut-off points” proposed for FeNO diagnosis of airways inflammation, noting an “enormous difference” in the maximum level of FeNo according to people’s age, sex and smoking status.

The other main difference concerned add-on therapy for people who were uncontrolled on inhaled corticosteroids (ICS). BTS suggests a long-acting beta agonist (LABA), usually in prescribed as a combination inhaler along with ICS.

NICE has plumped for the “miles cheaper” option of a trial of leukotriene receptor antagonists (LTRAs) for four to six weeks, said Dr Fowler.

He warned that this would cause “confusion” and possibly “differential adherence,” with patients choosing to take either their oral LTRA or inhaled ICS, not both.

“I think it’s ridiculous we’ve got two sets of guidelines. It could harm patients because of the confusion that results,” he said.

NICE guidelines can be viewed here

BTS/SIGN guidelines can be viewed here