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Editorials

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

Rapid Response:

Re: Conflicting asthma guidelines cause confusion in primary care

BMJ Rapid Response re: Keeley and Baxter: Conflicting asthma guidelines cause confusion in primary care

Matthew Hoghton1, Victoria Tzortiou Brown2, Imran Rafi3
1 and 3 RCGP Clinical Innovation and Research
2. Honorary Secretary RCGP

We welcome the Primary Care Respiratory Society (PCRS) editorial 1 and its broader perspective on asthma diagnosis and management in the light of relevant guidance from National Institute for Health and Care Excellence (NICE) 2 and British Thoracic Society/ Scottish Intercollegiate Guideline Network (BTS/SIGN) 3.

The Royal College of General Practitioners (RCGP) has supported the work of NICE since its inception in 1999. The Clinical Knowledge summaries (CKS) are based on the NICE guidelines have been used by generations of GPs at the point of care to help inform best clinical practice.

However, we share the concerns raised in the editorial by Kelley and Baxter on behalf of the PCRS about recommending an asthma diagnostic test (FeNo) that is not easily available within primary care .

The editorial also highlights the importance of reserving patient secondary care referrals for those patients who are identified as high risk (e.g. from the Review of Asthma deaths 4. Most asthma diagnosis is done in primary care, reducing demand on secondary services and referrals made to secondary care when there is diagnostic uncertainty.
The British Thoracic Society (BTS) 6 have identified the key differences between the BTS/SIGN and NICE guidelines on the diagnosis and management of asthma. These include diagnosis, pharmacological management, the introduction of leukotriene receptor antagonists (LTRA) after low dose inhaled corticosteroids (ICS), maintenance and reliever therapy (MART) and treatment beyond combined inhaler therapy as well as some other issues in managing asthma in children. The BTS/SIGN guidelines also provide recommendations on inhaler devices, the management of acute asthma attacks in both adults and children, the management of difficult to control asthma and the management of asthma in adolescents, in pregnant women and due to occupational factors.

The methodology used by NICE in the production of single unified guidelines on a clinical area helps to reduce the potential of over-representation of any organisation, specialist group or pharmaceutical company and aims to provide clarity for health care professionals, patients and their families. NICE generally does not reproduce a guideline where another body has created an NICE-accredited guideline with the exception of the BTS/Sign Asthma guidelines 5. Keeley and Baxter call for a unified guidance that covers diagnosis and management as well as economic analysis combining the strengths of both organisations. We agree that such an approach can reduce the confusion that might have inadvertently arisen across the UK. It is encouraging that NICE seems to stand ready to take the next steps in developing such a joint approach.

References.
1. Keely D and Baxter N, 2018. www.bmj.com/content/360/bmj.k29
2. National Institute for Health and Care Excellence (NICE) Asthma diagnosis, monitoring and chronic asthma management, 2017. https://www.nice.org.uk/guidance/ng80
3. British Thoracic Society/ Scottish Intercollegiate Guideline Network. British Guidelines on the management of asthma. 2016. http://www.sign.ac.uk/assets/sign153.pdf
4. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential
Enquiry report. London: RCP, 2014.
5. www.nice.org.uk/About/What-we-do/Accreditation/Accreditation-decisions (accessed 13.1.2018)
6. White J, Paton JY, Niven R, et al Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE Thorax Published Online First: 03 January 2018. doi: 10.1136/thoraxjnl-2017-211189

Competing interests: No competing interests

01 February 2018
Imran Rafi
GP
Matthew Hoghton and Victoria Tzortiou -Brown
RCGP
RCGP, 30 Euston Square, london NW1