TRUST GUIDELINE

Guidelines for the Management of Asthma in Adults

APPROVING COMMITTEE(S) Drugs and Therapeutic Committee

Date approved: 6.6.18

EFFECTIVE FROM 6.6.18

DISTRIBUTION

North East Central London Asthma Committee

WEL MOCC- NHS Newham CCG, NHS Tower Hamlets CCG, NHS Waltham Forest CCG

ARCaRe

RELATED DOCUMENTS

BTS/SIGN Asthma Guidelines 2016. The BTS/SIGN Guideline for the management of asthma published on 21 September 2016. 2016

NICE Asthma: diagnoses, monitoring and chronic asthma management guidelines published November 2017

STANDARDS BTS/SIGN

OWNER Dr. Paul Pfeffer, Consultant Respiratory Physician with Specialist Academic Interest in Asthma

AUTHOR/FURTHER INFORMATION

Bijal Gandhi, Highly Specialist Severe Asthma and Allergy pharmacist

Dr. Paul Pfeffer, Consultant Respiratory Physician with Specialist Academic Interest in Asthma

SUPERCEDED DOCUMENTS -

VERSION 1

REVIEW DUE June 2019

KEYWORDS Asthma, Respiratory, Adult

INTRANET LOCATION(S) http:// [file location]

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Barts Health In consultation with respiratory consultants across Barts Health

External Partner(s)

North East Central London Asthma Committee

WEL MOCC- NHS Newham CCG, NHS Tower Hamlets CCG, NHS Waltham Forest CCG

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Included in guideline:

All Trust staff, working in whatever capacity and GP partners

Other staff, students and contractors working within the Trust

Exempted from guideline:

No staff groups are exempt from this policy.

Barts Health NHS Trust and WELMOCC

Guidelines for the Management of Asthma

Please find accompanying this letter the new Barts Health NHS Trust and WELMOCC Guidelines for the Management of Asthma. These have been revised with focus on an underlying principle that the least clinically effective and least cost effective asthma medications are those that the patient cannot or will not take correctly. There is good evidence from local and international research that patients who do not take their preventer inhaler as often as prescribed, but over rely on reliever inhalers, have worse asthma outcomes [1] [2]. Reasons for non-adherence to preventer inhalers are both intentional and non-intentional, and clinical evidence suggests that individual patient beliefs and lifestyle behaviours / choices are an important determinant of adherence to inhalers, with reduced adherence when patient beliefs do not align with choice of inhaler [3] [4]. Even if adherent, patients with poor inhaler technique, with resultant poor drug delivery to the lungs, have worse outcomes [5]. Inhaler technique, and inspiratory flow capacity, are important determinants of whether an individual patient would be best treated with traditional pressurised metred dose inhalers (pMDIs) or dry powder inhalers (DPIs) [6] [7]. Ideally an individual patient should have a consistent device-type for all their inhalers – using both pMDIs and DPIs in the same patient is associated with significantly worse inhaler technique likely as a result of confusion between different techniques for different inhalers [8]. Unintentional confusion and errors in inhaler technique when switching between different devices is the major reason that inhalers should be prescribed specifically by brand name and device – changing inhaled medication from one device-type to another (even without changing the actual drugs) is often associated with worsening disease control likely due in part to poor technique with the new device [9].

Therefore this Guideline focuses on correct choice of inhaler device-type before choice of drug molecule and dose. Specifically the Guideline advises consideration of whether a patient has the correct technique for pMDIs or DPIs as the first decision-step in choice of asthma medication. This is easy to check with inhaler whistles and placebo trainer inhalers, or with an In-Check DIAL device (essentially a reverse peak flow metre) [7]. As a second decision-step the Guideline advises consideration of the patient’s beliefs and behaviours to help guide choice between traditional twice-daily inhalers, once-daily inhalers or MART (maintenance and reliever therapy 2-in-1) inhalers. After these considerations the appropriate inhaler(s) for an individual can be decided depending on necessary medication strength. Different inhaler device-types are arranged horizontally in the Guideline chart and different strength medications vertically.

Respiratory Medicine

Barts Health NHS Trust

www.bartshealth.nhs.uk

17th April 2018

Releasing this new formulary guideline at a time of national anxiety about asthma guidelines, and in particular concerns regarding disagreements between the national NICE and national BTS-SIGN asthma guidelines, has led to this accompanying statement being written. It is important to note that the two national guidelines agree in more areas than disagree [10]. Some of these disagreements relate to different relative weighting of clinical effectiveness and cost effectiveness (health economic) analyses, and other disagreements relate to areas for which we have little current evidence and over which experts disagree. Both national guidelines in general give guidance on the preference order for prescription of different classes of asthma medication, rather than guidance on specific brands of inhaler or device-type. This is largely due to the greater research literature comparing classes of asthma medication rather than comparing inhaler device-types. Therefore the Barts Health NHS Trust / WELMOCC Guidelines and national guidelines are complimentary, with our guideline focussing on device-types and local cost factors for different inhalers, whilst national guidelines focus on choice between different classes of asthma medication.

That said there are some differences between our Guidelines and national guidelines.

This is to recognise that decision making should always be governed in the first instance by what is clinically appropriate for the individual patient. This may sometimes result in slight deviances from guidelines.

In particular our guideline continues to advise a step-up from ICS (inhaled corticosteroid) mono-inhaler to ICS-LABA (inhaled corticosteroid – long-acting beta-2 agonist) combination inhaler treatment in patients with uncontrolled asthma before trying addition of Monteleukast.

In addition, the writing of our Guideline was started before the final NICE Guideline was released and this aspect of our Guideline may change in the future in part depending on further consideration of whether adding an oral tablet may or may not be associated with decreased inhaler adherence as medication burden increases.

Secondly we have advised consideration of MART therapy, as an alternative to traditional separate reliever and preventer inhalers, at an earlier stage in asthma management than suggested in the NICE Guideline. There is much ongoing research on how to best place MART within treatment ladders and this guidance may change over time.

Thirdly there is much current debate over whether all patients with very mild asthma need to be on a preventer inhaler (a point of disagreement between the two current national guidelines). Our guideline can be used in conjunction with either approach.

Finally we have advised 12 months of asthma stability before considering stepping-down asthma medication strength. Asthma is seasonal with increasing evidence that loss of control of asthma inflammation often leads to exacerbations occurring after a lag of several

months rather than immediately. We would therefore advise that 3 months of asthma stability is insufficient to conclude the patient is safe to try reducing asthma medication.

These Guidelines are intended to be collaborative and to evolve over time, in response to concerns and opinions of clinicians in the region; so please be in touch with any questions or comments. We aim to revise these guidelines annually in line with updates to national guidance, changes in local medication costs and new evidence.

Yours faithfully,

Paul

Dr Paul E Pfeffer MRCP PhD

Consultant Respiratory Physician with Specialist Academic Interest in Asthma

& Joint Lead North Central and East London Severe Asthma Service,

St Bartholomew’s Hospital, Barts Health NHS Trust; paul.pfeffer@bartshealth.nhs.uk

Honorary Senior Lecturer,

William Harvey Research Institute, Queen Mary University of London; p.pfeffer@qmul.ac.uk

1. Hull, S.A., et al., Asthma prescribing, ethnicity and risk of hospital admission: an analysis of 35,864 linked primary and secondary care records in East London. NPJ Prim Care Respir Med, 2016. 26: p. 16049.

2. Williams, L.K., et al., Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol, 2004. 114(6): p. 1288-93.

3. Chiu, K.C., et al., Patients' beliefs and behaviors related to treatment adherence in patients with asthma requiring maintenance treatment in Asia. J Asthma, 2014. 51(6): p. 652-9.

4. Ahmed, S., et al., Blue inhalers: blowing hot and cold. NPJ Prim Care Respir Med, 2017. 27(1): p. 6.

5. Melani, A.S., et al., Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med, 2011. 105(6): p. 930-8.

6. Borgström, L., et al., Lung deposition of budesonide inhaled via Turbuhaler®: a comparison with terbutaline sulphate in normal subjects. European Respiratory Journal, 1994. 7(1): p. 69-73.

7. Chrystyn, H., Is inhalation rate important for a dry powder inhaler? Using the In-Check Dial to identify these rates. Respir Med, 2003. 97(2): p. 181-7.

8. van der Palen, J., et al., Multiple inhalers confuse asthma patients. Eur Respir J, 1999. 14(5): p. 1034-7.

9. Bjornsdottir, U.S., S. Gizurarson, and U. Sabale, Potential negative consequences of non-consented switch of inhaled medications and devices in asthma patients. Int J Clin Pract, 2013. 67(9): p. 904-10.

10. White, J., et al., Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE. Thorax, 2018. 73(3): p. 293-297.

Observe the patient inhaler technique.

Assess the patient’s inspiratory ability e.g. using In-

check device and check patient preference for device.

Able to take a slow and

steady breathe in and/or

prefers pMDI

Able to take in a quick and

deep breath in.

Provide a pMDI with a spacer (options below) to be

changed every year. Consider a dry powder inhaler (options below)

Evaluation

- Check patient’s

adherence - Provide a personalised

action plan - Refer patients to

smoking cessation

services as appropriate

Asthma Prescribing Guidelines

for Adults

Prescribing

Always prescribe

inhalers via BRAND and

DEVICE.

Low dose ICS Medium dose ICS High dose ICS MART therapy

Asthma Inhaler Guide

SABA LAMA ICS LABA/ICS EXTRAS

Salamol

Salbutamol 100mcg/ inhalation

Salamol easi-

breath Salbutamol 100mcg/ inhalation

Spiriva Respimat SMI Tiotropium 2.5mcg/inhalation

Flixotide

Evohaler Fluticasone Propionate

50, 125, 250mcg inhalers

Flixotide Accuhaler Fluticasone Propionate

50, 100, 250, 500mcg inhalers

Flutiform

Formoterol/Fluticasone propionate 50/5, 125/5, 250/5mcg inhalers

Seretide Evohaler Salmeterol/ Fluticasone

propionate 25/50, 25/125, 25/250mcg inhalers

Seretide Accuhaler Salmeterol/ Fluticasone

propionate 50/100,50/25050/500mcg

inhalers

Aerochamber

Airomir Autohaler Salbutamol 100mcg/

inhalation

Easyhaler Salbutamol Salbutamol 100-200mcg

inhalers

Clenil Modulite Beclomethasone dipropionate 50, 100, 200, 250mcg inhalers

Fostair Beclometasone/ Formoterol

100/6, 200/6mcg

inhalers

Fostair Nexthaler Beclometasone/ Formoterol

100/6, 200/6mcg

inhalers

Relvar Ellipta Vilanterol/Fluticasone furoate 22/92, 22/184mcg inhalers

Volumatic Spacer

Ventolin

Accuhaler Salbutamol 200mcg/ blister

Ventolin

Evohaler Salbutamol 100mcg/ inhalation

Qvar Beclomethasone

dipropionate 50,100mcg

inhalers

Qvar easi-breath Beclomethasone dipropionate

50,100mcg inhalers

Duoresp Spiromax Budesonide/Formoterol 160/4.5mcg, 320mcg/9mcg inhalers

AirFluSal Salmeterol/Fluticasone Propionate 25/125, 25/250mcg inhalers

In-Check Dial

Bricanyl Turbohaler Terbutaline sulphate 0.5mg/inhalation

Pulmicort Turbohaler Budesonide

100, 200, 400mcg

Symbicort Turbohaler Budesonide/Formoterol 100/6, 200/6, 400/12mcg

inhalers

Sirdupla Salmeterol/Fluticasone Propionate 25/125, 25/250mcg

inhalers

Peak Flow Meter

SABA – Short-acting beta2 agonist

LABA – Long-acting beta2 agonist LAMA – Long-acting muscarinic

antagonist

ICS – Inhaled corticosteroid

LTRA- Leukotriene receptor antagonist

P- puf f

mcg- microgram BD- twice daily

OD- once daily

PRN- when required

pMDI – Pressured Metered Dose

Inhaler DPI – Dry Powder Inhaler

SMI – Sof t Mist Inhaler

MART- maintenance and reliev er

therapy

References BTS/SIGN Asthma Guidelines 2016. The BTS/SIGN Guideline for the management of asthma published on 21 September 2016.

2016: Accessed 8-2-17.

NICE Asthma: diagnoses, monitoring and chronic asthma management guidelines published November 2017, accessed 4th

Jan 2018.

UK Inhaler group. Inhaler standards and competency document. Scullion J, Respiratory Nurse Consultant, University hospital of Leicester NHS Trust. Contributors Murphy, Anna. Consultant Pharmacist, University Hospitals of Leicester. Published December 2016.

Global Initiative for Asthma. Global Strategy for Asthma management and prevention. 2017 update. British National Formulary. Year of publication 2017. Edition 73. London. BMJ Group and Pharmaceutical Press. QOL Tech. Measurement of Health-Related Quality of life & Asthma control. 1999; Available at:

https://www.qoltech.co.uk/miniaqlq.html. Accessed 20th July 2017. Asthma.com. Asthma Control Test. 2017; Available at: http://www.asthma.com/additional-resources/asthma-control-

test.html. Accessed 20th

July 2017.