Managing asthma - NICE Pathways · Managing asthma NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed

Managing asthmaManaging asthma

NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/asthmaNICE Pathway last updated: 10 May 2019

This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.

AsthmaAsthma© NICE 2020. All rights reserved. Subject to Notice of rights.

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Managing asthmaManaging asthma NICE Pathways


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1 Person with suspected or confirmed asthma

No additional information

2 Principles of care

Take into account the possible reasons for uncontrolled asthma [See page 21], before starting

or adjusting medicines for asthma in adults, young people and children. These may include:

alternative diagnoses

lack of adherence

inappropriate inhaler technique

smoking (active or passive)

occupational exposures

psychosocial factors

seasonal or environmental factors.

After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8

weeks (see monitor and review).

If ICS maintenance therapy is needed, offer regular daily ICS rather than intermittent or 'when

required' ICS therapy.

Adjust the dose of ICS maintenance therapy over time, aiming for the lowest dose required for

effective asthma control.

Ensure that a person with asthma can use their inhaler device:

at any asthma review, either routine or unscheduled

whenever a new type of device is supplied.

For guidance on managing non-adherence to medicines in people with asthma, see NICE's

recommendations on supporting adherence.

Consider using risk stratification [See page 21] to identify people with asthma who are at

increased risk of poor outcomes, and use this information to optimise their care. Base risk

stratification on factors such as non-adherence to asthma medicines, psychosocial problems

and repeated episodes of unscheduled care for asthma.



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https://pathways.nice.org.uk/pathways/medicines-optimisation/medicines-optimisation-overview#content=view-node%3Anodes-supporting-adherence


Doses of inhaled corticosteroids

ICS doses and their pharmacological strengths vary across different formulations. In general,

people with asthma should use the smallest doses of ICS that provide optimal control for their

asthma, in order to reduce the risk of side effects.

The following definitions can be used to guide doses of ICSs.

For adults aged 17 and over:

less than or equal to 400 micrograms budesonide or equivalent would be considered a lowdose

more than 400 micrograms to 800 micrograms budesonide or equivalent would beconsidered a moderate dose

more than 800 micrograms budesonide or equivalent would be considered a high dose.

For children and young people aged 16 and under:

less than or equal to 200 micrograms budesonide or equivalent would be considered apaediatric low dose

more than 200 micrograms to 400 micrograms budesonide or equivalent would beconsidered a paediatric moderate dose

more than 400 micrograms budesonide or equivalent would be considered a paediatric highdose.

Intrapartum care

See what NICE says on intrapartum care for women with asthma.

3 Drug treatment

No additional information

4 Under 5s

These recommendations are for children under 5 with newly suspected or confirmed asthma, or

with asthma symptoms that are uncontrolled on their current treatment. Where the

recommendations represent a change from traditional clinical practice, children whose asthma

is well controlled on their current treatment should not have their treatment changed purely to

follow this guidance.



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https://pathways.nice.org.uk/pathways/intrapartum-care-for-women-with-existing-medical-conditions/intrapartum-care-for-women-with-existing-medical-conditions-overview#content=view-node%3Anodes-asthma


Offer a SABA as reliever therapy to children under 5 with suspected asthma. This should be

used for symptom relief alongside all maintenance therapy.

Consider an 8 week trial of a paediatric moderate dose of an ICS in children under 5 with:

symptoms at presentation that clearly indicate the need for maintenance therapy (forexample, asthma-related symptoms 3 times a week or more, or causing waking at night) or

suspected asthma that is uncontrolled with a SABA alone.

After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms:

if symptoms did not resolve during the trial period, review whether an alternative diagnosisis likely

if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart theICS at a paediatric low dose as first-line maintenance therapy

if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeatthe 8 week trial of a paediatric moderate dose of ICS.

If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as

maintenance therapy, consider an LTRA1 in addition to the ICS.

If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS and an

LTRA as maintenance therapy, stop the LTRA and refer the child to a healthcare professional

with expertise in asthma for further investigation and management.

See principles of care [See page 3] for information on ICS doses.

Inhaled corticosteroids

The following recommendation is an extract from NICE technology appraisal guidance on

inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12

years.

For children under the age of 12 years with chronic asthma in whom treatment with an ICS is

considered appropriate, the least costly product that is suitable for an individual child (taking into

consideration technology appraisal guidance 38 and 10), within its marketing authorisation, is

recommended.

This recommendation should be read in conjunction with the recommendations in inhaler

devices [See page 12].


1 At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children


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http://www.nice.org.uk/guidance/TA131



and young people aged under 18 for this indication.


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NICE has written information for the public on inhaled corticosteroids for the treatment of

chronic asthma in children under the age of 12 years.

5 Person aged 5 to 16

These recommendations are for children and young people with newly diagnosed asthma or

asthma that is uncontrolled on their current treatment. Where the recommendations represent a

change from traditional clinical practice, children and young people whose asthma is well

controlled on their current treatment should not have their treatment changed purely to follow

guidance.

Offer a SABA as reliever therapy to children and young people (aged 5 to 16) with newly

diagnosed asthma.

For children and young people (aged 5 to 16) with asthma who have infrequent, short-lived

wheeze and normal lung function, consider treatment with SABA reliever therapy alone.

Offer a paediatric low dose of an ICS as the first-line maintenance therapy to children and

young people (aged 5 to 16) with:


asthma that is uncontrolled with a SABA alone.

If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose

of ICS as maintenance therapy, consider an LTRA1 in addition to the ICS and review the

response to treatment in 4 to 8 weeks.


of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA2

in combination with the ICS.


of ICS and a LABA as maintenance therapy, consider changing their ICS and LABA

maintenance therapy to a MART regimen3 with a paediatric low maintenance ICS dose. Ensure

that the child or young person is able to understand and comply with the MART regimen.

If asthma is uncontrolled in children and young people (aged 5 to 16) on a MART regimen with a

paediatric low maintenance ICS dose, consider increasing the ICS to a paediatric moderate



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http://www.nice.org.uk/guidance/ta131/informationforpublic



1 At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children

and young people aged under 18 for this indication.2 At the time of publication (November 2017), not all LABAs have a UK marketing authorisation for use in children

and young people aged under 18 for this indication.3 At the time of publication (November 2017), MART regimens did not have a UK marketing authorisation for use in

children and young people (aged under 12) for this indication. The prescriber should follow relevant professional

guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the

GMC's Prescribing guidance: prescribing unlicensed medicines for further information.


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http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp


maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS

and a LABA, with a SABA as a reliever therapy).

If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric moderate

maintenance ICS dose with LABA (either as MART or a fixed-dose regimen), consider seeking

advice from a healthcare professional with expertise in asthma and consider either:

increasing the ICS dose to paediatric high maintenance dose (only as part of a fixed-doseregimen, with a SABA used as a reliever therapy) or

a trial of an additional drug (for example, theophylline).


Inhaled corticosteroids and long-acting beta-2 agonists

Under 12s

The following recommendations are from NICE technology appraisal guidance on inhaled

corticosteroids for the treatment of chronic asthma in children under the age of 12 years.

For children under the age of 12 years with chronic asthma in whom treatment with an ICS is

considered appropriate, the least costly product that is suitable for an individual child (taking into

consideration technology appraisal guidance 38 and 10), within its marketing authorisation, is

recommended.

For children under the age of 12 years with chronic asthma in whom treatment with an ICS and

LABA is considered appropriate, the following apply.

The use of a combination device within its marketing authorisation is recommended as anoption.

The decision to use a combination device or the two agents in separate devices should bemade on an individual basis, taking into consideration therapeutic need and the likelihood oftreatment adherence.

If a combination device is chosen then the least costly device that is suitable for theindividual child is recommended.

These recommendation should be read in conjunction with the recommendations in inhaler



chronic asthma in children under the age of 12 years.



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Person aged 12 or over


corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and

over.

For adults and children aged 12 years and older with chronic asthma in whom treatment with an

ICS is considered appropriate, the least costly product that is suitable for an individual, within its

marketing authorisation, is recommended.


ICS and LABA is considered appropriate, the following apply.



If a combination device is chosen then the least costly device that is suitable for theindividual is recommended.




chronic asthma in adults and in children aged 12 years and over.

6 Person aged 17 or over

These recommendations are for people with newly diagnosed asthma or asthma that is

uncontrolled on their current treatment. Where the recommendations represent a change from

traditional clinical practice, people whose asthma is well controlled on their current treatment

should not have their treatment changed purely to follow this guidance.

Offer a SABA as reliever therapy to adults (aged 17 and over) with newly diagnosed asthma.

For adults (aged 17 and over) with asthma who have infrequent, short-lived wheeze and normal

lung function, consider treatment with SABA reliever therapy alone.



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Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over)

with


asthma that is uncontrolled with a SABA alone.

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance

therapy, offer a LTRA in addition to the ICS and review the response to treatment in 4 to 8

weeks.

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as

maintenance therapy, offer a LABA in combination with the ICS, and review LTRA treatment as

follows:

discuss with the person whether or not to continue LTRA treatment

take into account the degree of response to LTRA treatment.

If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or

without an LTRA, as maintenance therapy, offer to change the person's ICS and LABA

maintenance therapy to a MART regimen with a low maintenance ICS dose.

If asthma is uncontrolled in adults (aged 17 and over) on a MART regimen with a low

maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate

maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS

and a LABA, with a SABA as a reliever therapy).

If asthma is uncontrolled in adults (aged 17 and over) on a moderate maintenance ICS dose

with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:

increasing the ICS to a high maintenance dose (this should only be offered as part of afixed-dose regimen, with a SABA used as a reliever therapy) or

a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist ortheophylline) or

seeking advice from a healthcare professional with expertise in asthma.


Inhaled corticosteroids and long-acting beta-2 agonists for person aged 12 or over




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corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and

over.


ICS is considered appropriate, the least costly product that is suitable for an individual, within its

marketing authorisation, is recommended.


ICS and LABA is considered appropriate, the following apply.



If a combination device is chosen then the least costly device that is suitable for theindividual is recommended.




chronic asthma in adults and in children aged 12 years and over.

Evidence summaries

NICE has published evidence summaries on:

asthma in adults: beclometasone/formoterol dry powder inhaler (Fostair NEXThaler)

asthma: fluticasone furoate/vilanterol (Relvar Ellipta) combination inhaler

asthma: beclometasone/formoterol (Fostair) for maintenance and reliever treatment

asthma: fluticasone/formoterol (Flutiform) combination inhaler.

7 Inhaler devices

NICE has published a medtech innovation briefing on Smartinhaler for asthma.

Under 5s

The following recommendations are from NICE technology appraisal guidance on the use of



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http://www.nice.org.uk/advice/ESNM53




http://www.nice.org.uk/advice/mib90



inhaler systems (devices) in children under the age of 5 years with chronic asthma.

For children under the age of 5 years with chronic stable asthma both corticosteroids and

bronchodilator therapy should be routinely delivered by pMDI and spacer system, with a

facemask where necessary.

Where this combination is not clinically effective for the child and depending on the child's

condition, nebulised therapy may be considered and in the case of children aged 3 to 5 years, a

DPI may also be considered.

Choice of device to be made within the pMDI and spacer range should be primarily governed by

specific individual need and the likelihood of good compliance. Once these factors have been

taken into account, choice should be made on the basis of cost minimisation.

NICE has written information for the public on the use of inhaler systems (devices) in children

under the age of 5 years with chronic asthma.

Person aged 5-15

The following recommendations are from NICE technology appraisal guidance on inhaler

devices for routine treatment of chronic asthma in older children (aged 5–15 years).

It is recommended that in addition to therapeutic need (including chosen drug and dose), the

following factors be taken into account when choosing inhaler devices for individual children

with chronic asthma:

the ability of the child to develop and maintain an effective technique with the specificdevice

the suitability of a device for the child's and carer's lifestyles, considering factors such asportability and convenience

the child's preference for and willingness to use a particular device.

The general recommendations above should be taken into account when considering the

following specific guidance:

A press-and-breathe pMDI and suitable spacer device is recommended as the first-linechoice for the delivery of inhaled corticosteroids as part of regular planned daily therapy,with the aim of maximising benefits of preventive therapy in attaining good asthma control,and minimising potential systemic absorption. Where clinicians believe that an individualchild's adherence to the press-and-breathe pMDI and spacer combination is likely to be sopoor as to undermine effective asthma control, other alternative devices (taking account ofevidence of equivalence of clinical effectiveness) should be considered, bearing in mind the



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need to minimise the risks of systemic absorption of corticosteroids.

In the case of other inhaled drugs, primarily bronchodilators, it is recommended that a widerrange of devices be considered to take account of their more frequent spontaneous use,the greater need for portability, and the clear feedback that symptom response provides tothe device user. In such circumstances the factors outlined above are likely to be of greaterimportance in choosing a device.

Where more than one device satisfies the considerations outlined above in a particularchild, it is recommended that the device with the lowest overall cost (taking into accountdaily required dose and product price per dose) should be chosen.

On selection of an inhaler device, it is important that consideration is given to other aspects of

asthma care that influence the effective delivery of inhaled therapy, including:

individual practical training in the use of the specific device

monitoring of effective inhaler technique and adherence to therapy

regular (i.e. no less than annual) review of inhaler needs, which may change over time withincreasing age.

NICE has written information for the public on inhaler devices for routine treatment of chronic

asthma in older children (aged 5–15 years).

8 Self-management

Offer an asthma self-management package, comprising a written personalised action plan and

education, to adults, young people and children aged 5 and over with a diagnosis of asthma

(and their families or carers if appropriate).

Consider an asthma self-management package, comprising a written personalised action plan

and education, for the families or carers of children under 5 with suspected or confirmed

asthma.

Within a self-management package, offer an increased dose of ICS for 7 days to adults (aged

17 and over) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly

outline in the person's asthma action plan how and when to do this, and what to do if symptoms

do not improve. When increasing the ICS dose:

consider quadrupling the regular ICS dose

do not exceed the maximum licensed daily dose.

Within a self-management package, consider an increased dose of ICS for 7 days for children



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and young people (aged 5 to 16) who are using an ICS in a single inhaler, when asthma control

deteriorates. Clearly outline in the person's asthma action plan how and when to do this, and

what to do if symptoms do not improve. When increasing ICS treatment:

consider quadrupling the regular ICS dose

do not exceed the maximum licensed daily dose.


Quality standards

The following quality statements are relevant to this part of the interactive flowchart.

Asthma

2. Written personalised action plan

Air pollution: outdoor air quality and health

4. Advice for people with chronic respiratory or cardiovascular conditions

9 Decreasing maintenance therapy

Consider decreasing maintenance therapy when a person's asthma has been controlled with

their current maintenance therapy for at least 3 months.

Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of

decreasing maintenance therapy.

When reducing maintenance therapy:

Stop or reduce dose of medicines in an order that takes into account the clinicaleffectiveness when introduced, side effects and the person's preference.

Only consider stopping ICS treatment completely for people who are using low dose ICSalone as maintenance therapy and are symptom free.

Agree with the person (or their family or carer if appropriate) how the effects of decreasing

maintenance therapy will be monitored and reviewed, including self-monitoring and a follow-up

with a healthcare professional.



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Review and update the person's asthma action plan when decreasing maintenance therapy.


10 Difficult and severe asthma

Omalizumab

The following recommendations are from NICE technology appraisal guidance on omalizumab

for treating severe persistent allergic asthma.

Omalizumab is recommended as an option for treating severe persistent confirmed allergic

IgE-mediated asthma as an add-on to optimised standard therapy in people aged 6 years and

older:

who need continuous or frequent treatment with oral corticosteroids (defined as 4 or morecourses in the previous year), and

only if the manufacturer makes omalizumab available with the discount agreed in thepatient access scheme.

Optimised standard therapy is defined as a full trial of and, if tolerated, documented compliance

with inhaled high-dose corticosteroids, LABA, leukotriene receptor antagonists, theophyllines,

oral corticosteroids, and smoking cessation if clinically appropriate.

People currently receiving omalizumab whose disease does not meet the criteria above should

be able to continue treatment until they and their clinician consider it appropriate to stop.

NICE has written information for the public on omalizumab.

See NICE's recommendations on smoking.

Temperature-controlled laminar airflow device

NICE has published a medtech innovation briefing on the Airsonett temperature-controlled

laminar airflow device for persistent allergic asthma.



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https://pathways.nice.org.uk/pathways/smoking

http://www.nice.org.uk/advice/MIB8



Severe eosinophilic asthma

Benralizumab

The following recommendations are from NICE technology appraisal guidance on benralizumab

for treating severe eosinophilic asthma.

Benralizumab, as an add-on therapy, is recommended as an option for treating severe

eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with

high-dose inhaled corticosteroids and long-acting beta-agonists, only if:

the person has agreed to and followed the optimised standard treatment plan and

the blood eosinophil count has been recorded as 300 cells per microlitre or more and theperson has had 4 or more exacerbations needing systemic corticosteroids in the previous12 months, or has had continuous oral corticosteroids of at least the equivalent ofprednisolone 5 mg per day over the previous 6 months (that is, the person is eligible formepolizumab) or

the blood eosinophil count has been recorded as 400 cells per microlitre or more with 3 ormore exacerbations needing systemic corticosteroids in the past 12 months (that is, theperson is eligible for reslizumab).

Benralizumab is recommended only if the company provides it according to the commercial

arrangement.

If benralizumab, mepolizumab or reslizumab are equally suitable, start treatment with the least

expensive option (taking into account drug and administration costs).

At 12 months:

stop benralizumab if the asthma has not responded adequately or

continue benralizumab if the asthma has responded adequately and assess response eachyear.

An adequate response is defined as:

a clinically meaningful reduction in the number of severe exacerbations needing systemiccorticosteroids or

a clinically significant reduction in continuous oral-corticosteroid use while maintaining orimproving asthma control.

These recommendations are not intended to affect treatment with benralizumab that was started

in the NHS before this guidance was published. People having treatment outside these



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recommendations may continue without change to the funding arrangements in place for them

before this guidance was published, until they and their NHS clinician consider it appropriate to

stop.

See why we made the recommendations on benralizumab.

NICE has written information for the public on benralizumab.

Reslizumab

The following recommendations are from NICE technology appraisal guidance on reslizumab

for treating severe eosinophilic asthma.

Reslizumab, as an add-on therapy, is recommended as an option for the treatment of severe

eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with

high-dose inhaled corticosteroids plus another drug, only if:

the blood eosinophil count has been recorded as 400 cells per microlitre or more

the person has had 3 or more severe asthma exacerbations needing systemiccorticosteroids in the past 12 months and

the company provides reslizumab with the discount agreed in the patient access scheme.

At 12 months:

stop reslizumab if the asthma has not responded adequately or

continue reslizumab if the asthma has responded adequately and assess response eachyear.


a clinically meaningful reduction in the number of severe exacerbations needing systemiccorticosteroids or

a clinically significant reduction in continuous oral corticosteroid use while maintaining orimproving asthma control.

These recommendations are not intended to affect treatment with reslizumab that was started in

the NHS before this guidance was published. Adults having treatment outside these

recommendations may continue without change to the funding arrangements in place for them

before this guidance was published, until they and their NHS clinician consider it appropriate to

stop.



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http://www.nice.org.uk/guidance/TA565/chapter/1-Recommendations





NICE has written information for the public on reslizumab.

Mepolizumab

The following recommendations are from NICE technology appraisal guidance on mepolizumab

for treating severe refractory eosinophilic asthma.

Mepolizumab, as an add-on to optimised standard therapy, is recommended as an option for

treating severe refractory eosinophilic asthma in adults, only if:

the blood eosinophil count is 300 cells/microlitre or more in the previous 12 months and

the person has agreed to and followed the optimised standard treatment plan and

has had 4 or more asthma exacerbations needing systemic corticosteroids in theprevious 12 months or

has had continuous oral corticosteroids of at least the equivalent of prednisolone 5mg per day over the previous 6 months and

the company provides the drug with the discount agreed in the patient access scheme.

At 12 months of treatment:

stop mepolizumab if the asthma has not responded adequately or

continue treatment if the asthma has responded adequately and assess response eachyear.


at least 50% fewer asthma exacerbations needing systemic corticosteroids in those peoplewith 4 or more exacerbations in the previous 12 months or

a clinically significant reduction in continuous oral corticosteroid use while maintaining orimproving asthma control.

This guidance is not intended to affect the position of patients whose treatment with

mepolizumab was started within the NHS before this guidance was published. Treatment of

those patients may continue without change to whatever funding arrangements were in place

for them before this guidance was published until they and their NHS clinician consider it

appropriate to stop.

NICE has written information for the public on mepolizumab.



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Bronchial thermoplasty

NICE has published interventional procedures guidance on bronchial thermoplasty for severe

asthma with standard arrangements for clinical governance, consent and audit.

NICE has published a medtech innovation briefing on Alair bronchial thermoplasty system for

adults with severe difficult to control asthma.

Tiotropium

NICE has published an evidence summary on asthma: tiotropium (Spiriva Respimat).

OxyMask

NICE has published a medtech innovation briefing on OxyMask for delivering oxygen therapy.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

Asthma

5. Suspected severe asthma (developmental)

11 Monitor and review

See Asthma/asthma overview /Monitor and review



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http://www.nice.org.uk/guidance/IPG635

http://www.nice.org.uk/guidance/IPG635




http://www.nice.org.uk/advice/mib160

https://pathways.nice.org.uk/pathways/asthma/asthma-overview#content=view-node%3Anodes-monitor-and-review


Risk stratification is a process of categorising a population by their relative likelihood of

experiencing certain outcomes. In the context of this guideline, risk stratification involves

categorising people with asthma by their relative likelihood of experiencing negative clinical

outcomes (for example, severe exacerbations or hospitalisations). Factors including non-

adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled

care can be used to guide risk stratification. Once the population is stratified, the delivery of

care for the population can be targeted with the aim of improving the care of the strata with the

highest risk.

Uncontrolled asthma

Uncontrolled asthma describes asthma that has an impact on a person's lifestyle or restricts

their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest

tightness associated with uncontrolled asthma can significantly decrease a person's quality of

life and may lead to a medical emergency. Questionnaires are available that can be quantify

this.

This guidance uses the following pragmatic thresholds to define uncontrolled asthma:

3 or more days a week with symptoms or

3 or more days a week with required use of a SABA for symptomatic relief or

1 or more nights a week with awakening due to asthma.

Glossary

BDR

bronchodilator reversibility

DPI

dry powder inhaler

Expiratory polyphonic wheeze

(a wheeze is a continuous, whistling sound produced in the airways during breathing. It is

caused by narrowing or obstruction in the airways; an expiratory polyphonic wheeze has

multiple pitches and tones heard over different areas of the lung when the person breathes out)



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FeNO

fractional exhaled nitric oxide

FEV1

forced expiratory volume in 1 second

FVC

forced vital capacity

Holiday

(any longer time away from work than usual breaks at weekends or between shifts)

ICS

inhaled corticosteroid

IgE

immunoglobulin E

LABA

long-acting beta-2 agonist

LABAs

long-acting beta-2 agonists

LTRA

leukotriene receptor antagonist

LTRAs

leukotriene receptor antagonists



Page 22 of 26


MART

(maintenance and reliever therapy is a form of combined ICS and LABA treatment in which a

single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance

therapy and the relief of symptoms as required; only available for ICS and LABA combinations

in which the LABA has a fast-acting component (for example, formoterol))

Objective test to diagnose asthma

(tests carried out to help determine whether a person has asthma, the results of which are not

based on the person's symptoms, for example, tests to measure lung function or evidence of

inflammation; there is no single objective test to diagnose asthma)

PC20

provoking concentration to induce a 20% reduction in forced expiratory volume in 1 second

pMDI

pressurised metered dose inhaler

ppb

parts per billion

title: Obstructive spirometry

FEV1/FVC ratio less than 70%

SABA

short-acting beta-2 agonist

SABAs

short-acting beta-2 agonists

Suspected asthma

(suspected asthma describes a potential diagnosis of asthma based on symptoms and



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response to treatment that has not yet been confirmed with objective tests)

Sources

Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80

Benralizumab for treating severe eosinophilic asthma (2019) NICE technology appraisal

guidance 565

Reslizumab for treating severe eosinophilic asthma (2017) NICE technology appraisal guidance

479

Mepolizumab for treating severe refractory eosinophilic asthma (2017) NICE technology

appraisal guidance 431

Omalizumab for treating severe persistent allergic asthma (2013) NICE technology appraisal

guidance 278

Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12

years and over (2008) NICE technology appraisal guidance 138

Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years

(2007) NICE technology appraisal guidance 131

Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years)

(2002) NICE technology appraisal guidance 38

Guidance on the use of inhaler systems (devices) in children under the age of 5 years with

chronic asthma (2000) NICE technology appraisal guidance 10

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful

consideration of the evidence available. When exercising their judgement, professionals and



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http://www.nice.org.uk/Guidance/NG80












practitioners are expected to take this guideline fully into account, alongside the individual

needs, preferences and values of their patients or the people using their service. It is not

mandatory to apply the recommendations, and the guideline does not override the responsibility

to make decisions appropriate to the circumstances of the individual, in consultation with them

and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline

to be applied when individual professionals and people using services wish to use it. They

should do so in the context of local and national priorities for funding and developing services,

and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to

advance equality of opportunity and to reduce health inequalities. Nothing in this guideline

should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of

implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, health

professionals are expected to take these recommendations fully into account, alongside the

individual needs, preferences and values of their patients. The application of the

recommendations in this interactive flowchart is at the discretion of health professionals and

their individual patients and do not override the responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable

the recommendations to be applied when individual health professionals and their patients wish

to use it, in accordance with the NHS Constitution. They should do so in light of their duties to

have due regard to the need to eliminate unlawful discrimination, to advance equality of

opportunity and to reduce health inequalities.






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https://www.nice.org.uk/about/who-we-are/sustainability





Medical technologies guidance, diagnostics guidance and interventional proceduresguidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after

careful consideration of the evidence available. When exercising their judgement, healthcare

professionals are expected to take these recommendations fully into account. However, the

interactive flowchart does not override the individual responsibility of healthcare professionals to

make decisions appropriate to the circumstances of the individual patient, in consultation with

the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful

discrimination, advance equality of opportunity, and foster good relations. Nothing in this

interactive flowchart should be interpreted in a way that would be inconsistent with compliance

with those duties.






Page 26 of 26




Documents

Managing asthma - NICE Pathways · Managing asthma NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed