Asthma NICE guidelines Flashcards
What are the three age categories for asthma treatment
- 12 and over
- 5-11
- under 5
diagnosing asthma in patients over 16 years
initial tests:
- blood eosinophil count
- FeNO level
Diagnose asthma if:
- raised eosinophil count
- FeNO level >50 ppb
then measure BDR with spirometry if still unable to diagnose
diagnose asthma if:
-FEV1 increase >12% from baseline and >200ml
- FEV1 increases >10% of the predicted FEV1
diagnosing asthma in patients aged 5 to 16 years
initial test:
FeNO level
diagnose asthma if:
- FeNO level >35 ppb
next measure BDR with spirometry
diagnose asthma if:
-FEV1 increase >10% of the predicted normal FEV1
- FEV1 increases >12% from baseline FEV1
Diagnosing asthma in under 5s
if suspected asthma:
- treat with ICS as per guidance
- regular review
- attempt tests when aged 5
Initial management of newly diagnosed asthma in people aged 12 and over
-Offer a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief (as-needed AIR therapy) to people aged 12 and over with newly diagnosed asthma.
-If the person needing asthma treatment presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation, start treatment with low-dose MART (maintenance and reliever therapy) in addition to treating the acute symptoms as indicated (that is, a course of oral corticosteroids may be needed). Consider stepping down to as-needed AIR therapy using a low-dose ICS/formoterol inhaler at a later date if their asthma is controlled.
what is AIR therapy
anti inflammatory reliever therapy
reliever: Formoterol combined with ICS
similar to MART but no maintenance dosing
only budesonide/formoterol inhalers licensed for AIR therapy
- low dose budesonide/formoterol combination recommended
- use of other ICS/formoterol inhalers is off license
Leukotriene receptor antagonists safety alert
MHRA safety advice
- risk of neuropsychiatric reactions with montelukast
- sleep disorders, hallucinations
- anxiety and depression
- changes in behaviour and mood
Medicine combination and sequencing in people aged 12 and over
-Offer low-dose MART to people aged 12 and over with asthma that is not controlled on a low-dose ICS/formoterol combination inhaler used only as needed.
-Offer moderate-dose MART to people aged 12 and over with asthma that is not controlled on low-dose MART.
-For people aged 12 and over with asthma that is not controlled on moderate-dose MART despite good adherence:
Check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count. If either of these is raised, refer to a specialist in asthma care.
If neither FeNO or eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART. Give the medicine for a trial period of 8 to 12 weeks unless there are side effects. At the end of the trial:
if asthma is controlled, continue the treatment
if control has improved but is still inadequate, continue the treatment and start a trial of the other medicine (LTRA or LAMA)
if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA).
Initial management in children aged 5-11
Offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a short-acting beta2 agonist (SABA) as needed, as initial treatment for children aged 5 to 11 years with newly diagnosed asthma
Medicine combination and sequencing in children aged 5 to 11
MART therapy
Consider paediatric low-dose MART (maintenance and reliever therapy) for children with asthma that is not controlled on paediatric low-dose ICS plus SABA as needed, as long as they are assessed to have the ability to manage a MART regimen.
In November 2024, no asthma inhalers were licensed for MART in children under 12, so this use would be off-label.
Consider increasing to paediatric moderate-dose MART if asthma is not controlled on paediatric low-dose MART.
Medicine combination and sequencing in children aged 5 to 11
- conventional pathway
Consider adding a leukotriene receptor antagonist (LTRA) to twice daily paediatric low-dose ICS plus SABA as needed when a child has uncontrolled asthma and is assessed as unable to manage the MART regimen. Give the LTRA for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective.
Offer a twice daily paediatric low-dose ICS/LABA (long-acting beta2 agonist) combination inhaler plus SABA as needed to children assessed as unable to manage the MART regimen if their asthma is not controlled on paediatric low-dose ICS plus SABA as needed (with or without an LTRA depending on previous response).
Offer a twice daily paediatric moderate-dose ICS/LABA inhaler plus SABA as needed to children with asthma that is not controlled on paediatric low-dose ICS/LABA plus SABA as needed (with or without an LTRA depending on previous response).
Pharmacological management in children under 5
Consider an 8 to12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [SABA] for reliever therapy) in children under 5 with suspected asthma and:
symptoms at presentation that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or
severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids).
Consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months.
If symptoms resolve during the trial period, but then:
symptoms recur by the 3-month review, or
the child has an acute episode requiring systemic corticosteroids or hospitalisation, restart regular ICS (begin at a paediatric low dose and titrate up to a paediatric moderate dose if needed) with SABA as needed and consider a further trial without treatment after reviewing the child within 12 months.
If suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy (with SABA as needed), consider a leukotriene receptor antagonist (LTRA) in addition to the ICS. Give the LTRA for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective.
Transferring people aged 12 and over from other treatment pathways
-Change treatment for people with confirmed asthma who are currently using a short-acting beta2 agonist (SABA) only to a low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy).
-Consider changing treatment to low-dose MART for people with asthma that is not controlled on:
-regular low-dose ICS plus SABA as needed
-regular low-dose ICS/LABA (long-acting beta2 agonist) combination inhaler plus SABA as needed
-regular low-dose ICS and supplementary therapy (LTRA) plus SABA as needed.
-regular low-dose ICS/LABA combination inhaler and supplementary therapy (LTRA) plus SABA as needed.
Consider changing treatment to moderate-dose MART for people with asthma that is not controlled on:
-regular moderate-dose ICS plus SABA as needed
-regular moderate-dose ICS/LABA combination inhaler plus SABA as needed
-regular moderate-dose ICS and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed
-regular moderate-dose ICS/LABA combination inhaler and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed.
