Introduction Asthma is a chronic respiratory condition affecting millions worldwide. To improve diagnostic accuracy and treatment outcomes, the National Institute for Health and Care Excellence (NICE), the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN) have jointly released updated asthma guidelines (published on November 27, 2024). These guidelines provide evidence-based recommendations for diagnosis, monitoring, and management of asthma in adults, young people, and children. This post highlights the key updates, treatment approaches, and how these changes impact clinical practice. 1. Improved Diagnostic Approach Asthma diagnosis is now more structured, with an emphasis on objective testing rather than relying solely on clinical history. ✅ Key Changes: A combination of tests should be used, as no single test is fully sensitive or specific. Adults (≥17 years): Start with blood eosinophil count or FeNO (fractional exhaled nitric oxide), followed by spirometry with bronchodilator reversibility (BDR) if asthma remains unconfirmed. Children (5–16 years): Measure FeNO first, then conduct spirometry with BDR. If inconclusive, further tests like peak expiratory flow (PEF) variability or IgE/eosinophil count are recommended. Children under 5 years: Diagnosis is symptom-based, with an 8–12 week trial of low-dose ICS to confirm response. 🔹 Clinical Impact: Routine spirometry is emphasised, following international standards. FeNO testing is now a recommended diagnostic tool. The use of PEF monitoring is limited to specific cases. 2. Monitoring Asthma Control Routine assessments are crucial for effective asthma management. ✅ Key Changes: Symptom assessment should include time off work/school, reliever inhaler use, and hospital visits. FeNO monitoring should be considered during routine reviews and when treatment changes are made. Routine PEF monitoring is NOT recommended, except in special cases. 🔹 Clinical Impact: Greater reliance on validated symptom questionnaires. FeNO testing may help tailor treatment adjustments more effectively. 3. Pharmacological Treatment Updates The biggest shift in asthma treatment involves the use of as-needed ICS/formoterol therapy instead of SABA alone. ✅ Key Changes: Short-acting beta2 agonists (SABA) should not be prescribed without an inhaled corticosteroid (ICS). For adults and children (≥12 years): First-line therapy: Low-dose ICS/formoterol inhaler as needed (As-needed AIR therapy). If uncontrolled: Low-dose MART (Maintenance and Reliever Therapy). If still uncontrolled: Moderate-dose MART, followed by FeNO and eosinophil testing before specialist referral. If biomarkers (FeNO/eosinophils) are low: Trial of LTRA or LAMA before referral. For children aged 5–11 years: First-line: Paediatric low-dose ICS (twice daily), with SABA as needed. If uncontrolled: Low-dose MART (if appropriate) or LTRA add-on therapy. For children under 5 years: 8–12 week ICS trial for suspected asthma; restart treatment if symptoms return. 🔹 Clinical Impact: ICS/formoterol preferred over SABA alone (a significant change from past guidelines). MART therapy emphasised for better symptom control. Stepwise treatment escalation based on biomarkers (FeNO, eosinophils). 4. Inhaler Use and Environmental Considerations The updated guidelines stress proper inhaler technique, patient preference, and environmental impact. ✅ Key Changes: Inhaler choice should prioritise: Ease of use (correct technique). Environmental impact (MDIs have high carbon footprints). Presence of a dose counter (to prevent overuse/underuse). Spacer devices are recommended, especially for children using metered-dose inhalers (MDIs). Digital inhalers are NOT recommended for routine use due to cost and lack of evidence. 🔹 Clinical Impact: Sustainable prescribing encouraged (use of low-carbon footprint inhalers). Greater emphasis on patient education for proper inhaler use. 5. Self-Management & Personalised Action Plans Patients should be empowered with personalised asthma action plans (PAAPs). ✅ Key Changes: PAAPs should include: Avoidance of personal triggers and air pollution exposure. Guidance on increasing ICS doses (for 7 days) when asthma control worsens. Children and young people need regular review of self-management strategies. 🔹 Clinical Impact: Encourages proactive patient involvement in asthma control. Promotes medication adherence and reduced emergency visits. 6. Risk-Stratified Care & Research Recommendations The guidelines introduce a risk-based approach to asthma management. ✅ Key Changes: Primary care services should implement risk-stratification tools to identify high-risk patients. Risk factors include: Non-adherence to medications. Overuse of SABA inhalers. Frequent exacerbations requiring urgent care. 🔹 Clinical Impact: Helps prevent severe asthma exacerbations through targeted interventions. Encourages further research on cost-effectiveness of diagnostic pathways and inhaler technique optimisation. Impact on Clinical Practice These updates will reshape asthma management in several key ways:✔ Increased use of FeNO testing for diagnosis and monitoring.✔ Reduced reliance on SABA alone—ICS/formoterol is now first-line.✔ MART therapy gains priority over traditional ICS + SABA regimens.✔ Greater focus on patient self-management with action plans.✔ Environmental sustainability considered in inhaler selection. Healthcare providers will need additional training, and primary care investment in FeNO and spirometry services will be essential for proper implementation. Final Thoughts: What This Means for You These 2024 NICE Asthma Guidelines provide a modernised, evidence-based approach to asthma diagnosis, monitoring, and treatment. By adopting biomarker-driven decisions, personalised action plans, and risk-stratified care, healthcare professionals can help patients achieve better asthma control and fewer exacerbations.
