For adults aged 17 and over, the initial treatment approach under NG80 is as follows:2

·       offer a short-acting beta2 agonist (SABA) as reliever therapy to adults with newly diagnosed asthma;

·       for those who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone;

·       offer a low dose of an inhaled corticosteroid (ICS) as the first-line maintenance therapy to adults who either have symptoms “that clearly indicate the need for maintenance therapy” (such as asthma-related symptoms three or more times a week, or causing the patient to wake at night), or if the asthma cannot be controlled with a SABA alone.

However, the BTS points to data from the National Review of Asthma Deaths showing that patients have died when only prescribed a SABA. The NG80 recommendation to initiate treatment with a SABA alone could be a retrograde step, says the BTS, as it “has the potential to encourage continued over-reliance on SABA.”10

Instead, the 2016 BTS/SIGN guideline for adults (and children over 5 years) says initial treatment should be a low-dose ICS and that patients should not be given SABA alone “except in the few with very occasional short-lived wheeze).”10

Stepping up treatment – NICE

Moving up the treatment hierarchy, NG80 says a leukotriene receptor antagonist (LTRA) can be used in addition to as ICS, if the low-dose ICS maintenance therapy is insufficient. This should be reviewed after 4-8 weeks.2

If an LTRA plus low-dose ICS as maintenance is insufficient, then a long-acting beta2 agonist (LABA) with a moderate-dose ICS can be tried, and consideration given as to whether or not to continue with the LTRA.

If the LABA plus ICS (with or without an LTRA) approach is not controlling the asthma, then consider maintenance and reliever therapy (MART) using a single combined ICS+LABA inhaler.

If this is insufficient, the recommended options are:

·       to step up the ICS to a high maintenance dose as part of a fixed-dose regimen, with a SABA used as a reliever therapy; or

·       adding in another drug such as a long-acting muscarinic receptor antagonist or theophylline; or

·       referral to a specialist.

BTS/SIGN stepping up treatment

Again, the BTS has a different approach to stepping up therapy. The BTS/SIGN guideline says low-dose ICS should be followed by addition of a LABA, in line with international guidelines such as the Global Initiative for Asthma (GINA).10

The BTS points out that NICE’s recommendation for a LTRA rather than LABA after ICS is due to cost-effectiveness criteria, although LABA is the more effective treatment. NICE estimates that the NHS could save around “£2 million a year for every 10,000 people who take up the new recommendation.”10,11

Nonetheless, the BTS acknowledges that “on a practical level, an increase in therapy from ICS alone to ICS/LABA, in most cases, only requires the name of the inhaler to be changed; the patient just continues using one inhaler as their preventer.”10

However, if a patient is prescribed LTRA therapy, this may require an oral therapy taken at night, which may have an effect on adherence to preventer inhaler use.

Other differences

The BTS also has concerns about the cost-effectiveness of introducing a LABA without having withdrawn an ineffective LTRA. Patient trust could also be diminished “through the initial use of a cheap but often ineffective treatment in place of an effective simple regimen,” it said.10

Furthermore, “a failure to gain asthma control may ultimately lead to avoidable attacks and associated costs through emergency attendances and even hospital admissions.”

There are also discrepancies between NG80 and the BTS/SIGN guideline around MART. While data indicates a MART regime reduces the number of asthma attacks in adults, the guidelines differ on when to try MART.

NG80 introduces MART when a low-dose ICS and LABA maintenance therapy (with or without LTRA) is not controlling asthma. The BTS/SIGN advice is that MART be considered for patients “who have a history of asthma attacks on medium-dose ICS or ICS/LABA.”10