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Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE

18 Dec, 17 | by rtaylor

John White, James Paton, Robert Niven, Hilary Pinnock
On behalf of the British Thoracic Society

The British Thoracic Society first produced a guideline on asthma and its management in 1990. The first collaborative guideline with the Scottish Intercollegiate Guideline Network (SIGN) using evidence-based medicine methodology was published in 2003 (1). It has since become a mainstay of asthma management across the UK and beyond, with updates published regularly every 18 to 24 months. The latest BTS/SIGN guideline for the management of asthma was published in 2016 (2).  Both BTS and SIGN are committed to continuing updates with the next update planned for publication in 2019.

Following publication of NICE Guidelines for diagnosis and monitoring, and for management of asthma (3, 4, 5) there are now two if not three national guidelines, for England at least, with some (apparently) striking differences. This statement considers the similarities and differences to assist clinical colleagues in the care of people with asthma.

The evidence base considered by the BTS/SIGN and NICE guideline development groups is broadly the same for each guideline, but the methodology used to produce recommendations is significantly different:

  • SIGN methodology is a multidisciplinary clinically-led process which employs robust critical appraisal of the literature, coupled with consideration of pragmatic studies to ensure that guidelines provide clinically-relevant recommendations;
  • NICE methodology overlays critical appraisal of the literature with health economic modelling, with interpretation supported by advice from a multidisciplinary Guideline Development Group.

These different processes have resulted in some discrepancies in recommendations made by BTS/SIGN and NICE.  This article seeks to provide some context to these differences in the key areas of:

  1. Diagnosis
  2. Pharmacological management
    • Treatment at diagnosis
    • The introduction of leukotriene receptor antagonists (LTRA) after low dose inhaled corticosteroids (ICS)
    • Maintenance and reliever therapy (MART)
    • Treatment beyond combined inhaler therapy
    • Some other issues in managing asthma in children

The BTS/SIGN guideline also provides recommendations for important aspects of asthma management that are not addressed within NICE guidelines. These include guidance on inhaler devices, the management of acute asthma attacks in both adults and children, the management of difficult asthma, guidance on asthma in adolescents, in pregnant women and on occupational factors.

Read the full article here.

This article is currently in press. It may subject to minor content and format changes before publication in the February 2018 issue of Thorax.

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  • While I agree this paper draws out most of the important issues related to the NICE guideline, I would like to point out that there are inaccuracies regarding the statements and table related to ‘dose equivalences’ in the GINA document ( page 7).
    In fact reference to equivalence in your article is explicitly contradicted by the statement immediately below GINA table 3-6. (www.ginasthma.org) Can I suggest this is corrected before publication in Thorax next month.
    Furthermore the GINA table also takes into account the potential for side-effects. For example, BDP HFA causes more adrenal suppression than FP HFA at the same dose. (http://onlinelibrary.wiley.com/doi/10.1046/j.0306-5251.2001.bjcp.1399.x/full)
    Of course this is going to get even more complicated with the number of generics now available, as they cannot be assumed to be equivalent to the original product, due to the impact of the inhaler device and additives.

    Dr Mark L Levy Respiratory Lead Harrow CCG; Member of the BTS/SIGN Acute Guideline Group; Board Member of GINA

  • Martin Duerden

    Could you clarify Table 1 of the BTS response to the NICE asthma guideline, to be published in Thorax?
    The inhaled corticosteroid doses used to categorise strength
    in GINA are daily doses. Although NICE does not state whether their doses are individual or daily, one assumes they are daily as they are derived from GINA.
    The Table in the BTS response appears to use the individual doses from the BTS/SIGN guideline (Table 10, page 72 of BTS/SIGN Guideline) which are then compared with daily doses.
    Is this correct (or does it need altering)?

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