The updated NICE asthma guidelines focus on improving diagnosis, monitoring, management, and self-management of asthma in adults, young people, and children. They emphasise accurate diagnostic techniques, regular monitoring, tailored pharmacological treatment, and proactive self-management strategies to improve asthma control and reduce exacerbations.

Below are the key takeaways:

Key Focus Areas

1. Diagnosis

   • Use clinical history and objective tests to confirm asthma.
   • Differentiate between age groups:
     • Adults (17+): Start with blood eosinophil count or FeNO levels. Use spirometry and bronchodilator reversibility (BDR) if inconclusive.
     • Children (5–16): Prioritise FeNO and spirometry; consider IgE testing and referral if uncertain.
     • Children (<5): Treat suspected asthma with low-dose ICS and refer if severe or recurrent symptoms occur.
   • Occupational asthma: Assess potential workplace triggers.

2. Monitoring

   • Regular reviews to assess symptom control, SABA use, and exacerbations.
   • Use validated symptom questionnaires (e.g., Asthma Control Questionnaire).
   • FeNO monitoring for adults before/after treatment changes to identify airway inflammation and adherence issues.
   • Avoid routine PEF monitoring, as it may worsen outcomes.

3. Pharmacological Management

   • ICS use: SABA-only regimens are discouraged—ICS must always accompany SABA prescriptions.
   • Tailor treatments based on age and severity:
     • Adults (12+): Initiate with low-dose ICS/formoterol as-needed; escalate to MART or add-on therapy (LTRA/LAMA) for uncontrolled asthma.
     • Children (5–11): Use twice-daily low-dose ICS with SABA; consider MART for uncontrolled asthma.
     • Children (<5): Use low-dose ICS trials; escalate or refer if symptoms persist.
   • Reduce maintenance therapy cautiously (8–12 weeks between reductions).

4. Self-Management

   • Offer personalised action plans with education on trigger avoidance and medication use.
   • Regularly review and update plans after exacerbations or admissions.
   • Allow ICS dose increases within action plans for deteriorating control.

5. Risk-Stratified Care

   • Identify at-risk individuals (e.g., frequent SABA users, poor adherence, recurrent hospitalisations).
   • Tailor care and prioritise follow-ups for high-risk patients.

Age-Specific Treatment Pathways

1. Adults and Young People (12+):

   • Initial treatment: Low-dose ICS/formoterol (as-needed).
   • Uncontrolled asthma:
     • Progress to low-dose MART.
     • Add LTRA or LAMA if moderate-dose MART is ineffective.
     • Specialist referral for severe cases.

2. Children (5–11):

   • Initial: Twice-daily low-dose ICS + SABA as needed.
   • If uncontrolled:
     • Transition to low-dose MART.
     • Consider LTRA or ICS/LABA for MART intolerance.
   • Refer to a specialist if moderate-dose therapy fails.

3. Children (<5):

   • Suspected asthma: Trial low-dose ICS, review regularly.
   • Escalate or restart ICS if symptoms persist; add LTRA if required.
   • Specialist referral for unresolved symptoms or frequent exacerbations.

Key Diagnostic and Monitoring Tools

1. Fractional Exhaled Nitric Oxide (FeNO):

   • Identifies airway inflammation and guides treatment adjustments.
   • Used to monitor adherence and determine the appropriateness of stepping down therapy.

2. Peak Expiratory Flow (PEF):

   • Limited role in routine monitoring; reserved for personalised action plans.

Other Key Recommendations

• Inhaler Selection: Tailor to patient preferences, technique, and environmental impact.
• Adherence Checks: Evaluate at every review to ensure optimal control.
• Digital Inhalers: Not recommended for routine use due to cost and lack of evidence.
• Asthma in Pregnancy: Maintain good control and continue medications.
• Asthma in Adolescents: Address smoking/vaping risks and career choices.

Research Priorities

The guideline identifies areas for further research:

• Comparing regular ICS regimens vs. as-needed strategies in children.
• Assessing the cost-effectiveness of diagnostic pathways.
• Determining the best methods for checking inhaler technique and monitoring adherence.

Practical Implications for Pharmacy Students

• Diagnosing: Understand the importance of FeNO and spirometry in confirming asthma.
• Monitoring: Familiarise yourself with symptom questionnaires and when to use FeNO or PEF.
• Pharmacology: Be prepared to explain MART regimens and ICS use to patients.
• Patient Education: Guide patients in creating personalised action plans and using inhalers correctly.
• Adherence Support: Counsel patients on the importance of medication adherence and regular reviews.

By adhering to these guidelines, healthcare professionals can provide effective, patient-centred care and minimise the risks associated with asthma.

References

1. National Institute for Health and Care Excellence (NICE). (2023). Asthma: Diagnosis, Monitoring, and Chronic Asthma Management (NG245). Retrieved from https://www.nice.org.uk/guidance/ng245

2. National Institute for Health and Care Excellence (NICE). (2023). Asthma: Recommendations. Retrieved from https://www.nice.org.uk/guidance/ng245/chapter/Recommendations

3. National Institute for Health and Care Excellence (NICE). (2023). Asthma: Recommendations for Research. Retrieved from https://www.nice.org.uk/guidance/ng245/chapter/Recommendations-for-research

4. National Institute for Health and Care Excellence (NICE). (2023). Asthma: Rationale and Impact. Retrieved from https://www.nice.org.uk/guidance/ng245/chapter/Rationale-and-impact