Joint guidance for asthma recommends replacing SABA with corticosteroid inhalers

Draft guidance for the diagnosis, monitoring and management of chronic asthma has recommended several changes to current clinical practice in the UK.

The recommendations — published on 28 June 2024 and compiled by the National Institute for Health and Care Excellence (NICE), the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) — include significant changes to the first-line treatment of newly diagnosed asthma. The guidance recommends the use of combined inhaled corticosteroid (ICS)/formoterol inhalers over previously preferred short-acting beta agonists (SABAs).

The proposed changes follow an evidence review, published alongside the draft guidance, carried out by an advisory committee, which revealed that using SABA alone in all age groups had the poorest clinical outcomes, despite being the cheapest option.

Other recommendations in the new draft guidance include the introduction of low-dose maintenance and reliever therapy (MART) in people aged 12 years and older with highly symptomatic or severe exacerbation of asthma, followed by addition of a leukotriene receptor antagonist (LTRA), and a long-acting muscarinic receptor antagonist (LAMA) if further control is needed.

In newly diagnosed children aged 5–11 years, twice-daily paediatric low-dose ICS is advised, with a SABA inhaler as needed, followed by paediatric low-dose MART for further control. The guidance says that treatment with LTRA or ICS/long-acting beta agonist may be considered where MART is inappropriate.

The guidance also recommends that a 8- to 12-week trial of twice-daily paediatric ICS should be considered in children aged under 5 years as maintenance therapy, in combination with SABA, as a reliever.

Commenting on the draft guidance, Darush Attar-Zadeh, clinical fellow respiratory pharmacist at the North West London Integrated Care Board, said: “The way asthma is managed needs to change. We’ve known for several decades now that asthma is a condition of inflammation.

“Unfortunately, it is still common practice for people living with asthma to be on two separate inhalers (SABA and ICS).

“An asthma attack is usually an indicator something went wrong with chronic treatment and under use of ICS and over-reliance of SABA is a common contributor to this, further exacerbated with poor inhaler technique and a lack of a co-created self-management plan.

“Pharmacists have a pivotal role in implementing the NICE/BTS/SIGN approach to management, offering patients a treatment (ICS/formoterol) that treats not only the symptoms but the actual cause (inflammation) at a time when they most need it,” he added.

The lack of a uniform approach to asthma diagnosis and management in the UK has generated criticism in recent years.

On its website, charity Asthma + Lung UK says there are 5.4 million people currently living with asthma in the UK, with 4 deaths resulting from the condition each day and tens of thousands of patients admitted to hospital for life-threatening asthma attacks each year.

Henry Gregg, director of external affairs at Asthma + Lung UK, said: “For too long there has been widespread complacency around asthma … asthma deaths have increased over the past decade and seven out of ten people aren’t receiving basic asthma care.

“The new national asthma guidelines will need to set out what is necessary to make sure every person with asthma is supported to take their preventer inhaler as prescribed, has an annual review, and receives a written asthma action plan.

“Pharmacists play an increasingly important role in asthma care and, for the guidelines to be effective, the next government must ensure they are backed by sufficient funding to ensure all services work for people with asthma, including pharmacies,” he added.

The draft guidance is open for public consultation until 30 July 2024, with final guidance due to be published on 27 November 2024.