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7th July 2009
SIGN and BTS have issued a revised British Guideline on the Management of Asthma. The 2009 update includes revisions to the sections on pharmacological management, acute asthma and the management of asthma in pregnancy.
Action
The revised SIGN/BTS British asthma guideline is an essential read for clinicians involved in the care of patients with asthma, particularly the updated sections on acute asthma and asthma in pregnant women. A quick reference guide is also available.
What has been updated?
The SIGN/BTS asthma guideline was previously updated and re-issued in May 2008. In this 2009 update, the familiar stepwise approach remains unchanged from previous versions. The only sections that have been revised are:
- Section 4 – pharmacological management
- Section 6 – management of acute asthma
- Section 7.3 – asthma in pregnancy
A full literature search was conducted on inhaler devices, but no new evidence was identified to alter current recommendations.
What are the new key messages?
The key messages from the new guidance include:
- Oxygen levels in patients with acute asthma should be maintained at SpO2 94–98%
- Oxygen saturation should be measured by pulse oximeters in adults and children. Pulse oximeters should be available for all health professionals assessing acute asthma in both primary and secondary care
- The importance of action plans in controlling asthma and reducing future hospitalisation is reinforced
- Advice on the safe use of treatment during pregnancy is reinforced.
Furthermore, the doses of inhaled corticosteroids (ICSs) were previously referenced against beclometasone (BDP) given via CFC-metered dose inhaler. This preparation has now been phased out, and the reference ICS is now BDP-HFA (CFC-free) equivalent. The updated SIGN/BTS guideline now contains a helpful table showing the equivalent doses of ICSs relative to BDP, and current licensed age indications.
The new guidance also states that:
In selected adult patients at step 3 who are poorly controlled or in selected adult patients at step 2 (above BDP 400 micrograms/day) who are poorly controlled, the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its use as controller therapy has been shown to be an effective treatment regime. Any patients taking rescue budesonide/formoterol once a day or more should have their treatment reviewed. Careful education of patients about the specific issues around this management strategy is required.
As we discussed in MeReC Bulletin Vol.19 No.2, patients selected for the key trials assessing the use of budesonide/formoterol as maintenance and reliever treatment were poorly controlled and all had experienced one or more severe exacerbation in the previous 12 months. Before initiating any new drug treatment, clinicians should check compliance with existing therapies, inhaler technique, and eliminate trigger factors where possible. The addition of a LABA to an ICS should be on an individual trial basis, and control of asthma should be assessed after an agreed duration, depending on the desired outcome. Advice on LABAs from the Commission on Human Medicines (CHM) should be followed:
In the management of chronic asthma, formoterol and salmeterol should:
- be added only if regular use of standard-dose ICS has failed to control asthma adequately
- not be initiated in patients with rapidly deteriorating asthma
- be introduced at a low dose and the effect properly monitored before considering dose increase
- be discontinued in the absence of benefit
- be reviewed as appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved.
Patients should report any deterioration in symptoms following initiation of treatment with a LABA.
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