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Conflicting asthma guidelines cause confusion in primary care

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k29 (Published 09 January 2018) Cite this as: BMJ 2018;360:k29

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Re: Conflicting asthma guidelines cause confusion in primary care

I welcome this editorial from the PCRS-UK, and agree with most of their points, particularly that the UK should have a single cohesive guideline for asthma care. The UK has the highest childhood death rates for asthma in Europe (1) and third highest in high income countries worldwide, (2) Furthermore the UK Government commissioned, national review of asthma deaths (NRAD) (3) demonstrated that over 60% of asthma deaths are associated with major preventable factors known for over 50 years, coupled with failure to implement the UK guidelines. Sadly, 18 of the 19 NRAD recommendations have not been implemented nationally nearly three years after publication, despite at least two subsequent high profile inquests resulting in Regulation 28 statements based on the coroners' conclusions these were preventable asthma deaths. (4, 5) In fact, the previously published National Institute for Health and Care Excellence (NICE) Quality Statement 25 (6) had not been implemented in my view, in either of these two cases; so rather than commissioning new guidelines, no doubt at considerable monetary expense and professional time, perhaps a national directive to implement existing guidelines and NRAD should have been placed!

While diagnostic hubs are a good idea, even the cash strapped NHS its unlikely that we will see these implemented in our lifetimes. It is hard to understand why NICE (7) have strongly recommended their diagnostic algorhythm despite such dismal results of their own feasibility study; which in my view should have been subjected to the same level of scientific rigour applied to the other evidence; with a logical conclusion to abandon it rather than herald its implementation - albeit phased. In particular : less than 30% of those eventually diagnosed with asthma had any evidence of airflow obstruction; 59% had an ‘uncertain diagnosis’; and it took an average of 57 minutes (range 30–100, SD 18) of scarcely available repeated consultation time in general practice to apply the algorhythm. (8)

On treatment, NICE quite correctly defines asthma as an inflammatory condition and yet, recommends, in my view, illogically and in contrast with the British Thoracic Society (BTS)/Scottish Intercollegiate Guideline Network (SIGN) guideline,(9) that short acting bronchodilator (SABA) reliever inhalers should be prescribed for newly diagnosed people with asthma. Furthermore, it is astounding that in contrast with BTS/SIGN, Global Initiative for Asthma (GINA) evidence based strategy document, (10) and systematic review evidence (11) most other international asthma guidelines in existence, NICE has recommended the addition of Leucotriene receptor antagonists (LTRAs) rather than long acting beta-agonists (LABAs) to treatment for people with poorly controlled asthma.

Hopefully, common sense will prevail and the powers that be will see fit to agree one clear, practical guideline for the UK; in my view, the evidence based, GINA Strategy, (10) which is written by experts, specifically for generalists, which is updated every six months, and free from political or industry influence, would be a good start – but then some may say I’m biased – being part of the GINA group as well as the Acute Asthma BTS/SIGN Guideline group!

Bibliography

1. Wolfe I, Thompson M, Gill P, Tamburlini G, Blair M, van den Bruel A, et al. Health services for children in western Europe. The Lancet. 2013;381(9873):1224-34.
2. Global Asthma Network. The Global Asthma Report 2014.2014. Available from: http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf.
3. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report: Royal College of Physicians. London; 2014 [Available from: http://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-fu....
4. Terrence Carney. Regulation 28 statement in the matter of Tamara Mills (Deceased). 2015 [Available from: https://www.judiciary.gov.uk/wp-content/uploads/2016/01/Mills-2015-0416.pdf.
5. Dr Shirley Radcliffe. Regulation 28 Statement in the matter of Michael Uriely (deceased) 2017 [Available from: https://www.judiciary.gov.uk/wp-content/uploads/2017/03/Uriely-2017-0069....
6. Asthma. NICE quality standard 25 (2013): National Institute for Health and Clinical Excellence; 2013 [updated 3/6/2013. Available from: http://publications.nice.org.uk/quality-standard-for-asthma-qs25.
7. NICE Asthma Guideline - Full Evidence 2017 [Available from: https://www.nice.org.uk/Guidance/NG80/Evidence
8. Commissioned by the National Institute for Health and Care Excellence (NICE). Asthma: diagnosis and monitoring of asthma in adults, children and young people. NICE guideline NG80 Appendices A - R 2017 [Available from: https://www.nice.org.uk/guidance/ng80/evidence/appendices-a-r-pdf-465617...
9. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 153 - The British Guideline on the Management of Asthma. 2016 [Available from: https://www.brit-thoracic.org.uk/document-library/clinical-information/a...
10. The Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA).2017. Available from: http://www.ginasthma.org/.
11. Chauhan BF, Ducharme FM. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma: John Wiley & Sons, Ltd; 2014 [Available from: http://dx.doi.org/10.1002/14651858.CD003137.pub5

Competing interests: I have no competing interest with regard to my letter which is written in the interest of people with asthma in the UK, who I believe are getting a raw deal through a lack of a national cohesive forward plan for managing asthma, preventing attacks and preventing preventable deaths. In the last two years I have accepted fees for Consultancy from Teva UK Limited, Novartis, Clement Clarke International, and Boehringer Ingelheim. For the sake of clarity: I have accepted lecture fees from - Teva UK Limited, AZ, GSK, Chiesi Pharmaceuticals, NAPP Pharmaceuticals mainly for lectures on the NRAD and lessons from asthma deaths. I have served on Drug Safety Monitoring Board for multinational studies by Chiesi Pharmaceuticals. I serve on the GINA Executive (no personal funding - however, travel and accommodation for meetings has been paid for)

09 January 2018
Mark L Levy
General Practitioner
Clinical Lead NRAD (2011-2014); Respiratory Clinical Lead Harrow Clinical Commissioning Group; Member of the BTS/SIGN Acute asthma group
Harrow, London