respiratory
Asthma

BTS/SIGN asthma guidelines: the next generation


The next iteration of the British Thoracic Society/Scottish Intercollegiate Guidelines Network asthma guidelines are likely to update advice on personalised risk management, allergens, acute management of attacks, breathing training and the place of immunotherapy.

The guideline development group has asked BTS members to comment on the proposed scope of the next 2018-2019 update, before they begin work on evidence search and appraisal in the New Year. A draft of the new guideline is expected in winter 2018.

BTS and SIGN has been producing joint guidelines for asthma management since 2003, updated every two to three years. However, newly published NICE guidelines on asthma – which differ in significant ways from BTS/SIGN – are likely to cause confusion.

BTS/SIGN guideline development group member Dr James Paton, presenting the questions for consultation, said he had “no idea” how the two guidelines could be brought together.

However, he said, “We’re clearly committed to producing an updated guideline for 2019. Two years from now it is likely that some things will be different from today.”

The key questions to determine the scope of the BTS/SIGN guideline fall into the field of monitoring, non-pharmacological management, pharmacological management, acute asthma rescue treatment, and dysfunctional breathing (see box below).

Dr Paton said they would consider individualised markers of risk to be aware of when monitoring asthma. “We are conscious there is a personalised medicine agenda and cross-cutting issues that may identify markers that highlight populations we need to take account of.”

Attendees at the BTS winter meeting, where the scoping questions were discussed, suggested the group should also consider initial therapy in children, medication side effects (specifically osteoporosis prophylaxis), exercise and treatment adherence monitoring.

According to the guideline development group, the key questions for monitoring are:

  • Which markers (eg symptom scores, blood tests, lung function tests, bronchial reactivity/airway challenge, FeNO) are most effective for assessing current asthma control, and which individual or combination or characteristics effectively predict future loss of control or future risk of attacks?
  • Are there interventions in the home/workplace/outdoor environment that improve asthma control and prevent attacks?
  • In people with asthma not adequately controlled by lose dose or very low dose ICS, which initial add-on therapy is most effective, and in people with asthma whose symptoms are not adequately controlled by low dose ICS plus LABA, what is more effective than placebo?
  • In people with asthma at the onset of an attack, does increasing ICS, compared to usual care as part of a self-management plan, reduce severity or improve asthma control?
  • Is sublingual immunotherapy effective, compared to standard therapy?
  • Does extracorporeal membrane oxygenation or other potential rescue therapies improve survival or other outcomes, in immediate treatment of people with life-threatening asthma?
  • Is breathing training in additional to usual care effective?