Asthma Asthma Management

Asthma management

A NICE pathway brings together all NICE guidance, qualitystandards and materials to support implementation on a specifictopic area. The pathways are interactive and designed to be usedonline. This pdf version gives you a single pathway diagram anduses numbering to link the boxes in the diagram to the associatedrecommendations.

To view the online version of this pathway visit:

http://pathways.nice.org.uk/pathways/asthma

Pathway last updated: 13 January 2015Copyright NICE 2015. All rights reserved

NICEPathwaysPathways

Asthma management NICE Pathways

Asthma pathwayCopyright NICE 2015. Pathway last updated: 13 January 2015

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1 Person with chronic asthma

No additional information

2 Inhaled corticosteroids

Chronic asthma in children aged under 12 years

This guidance should be read in conjunction with the recommendations on inhaler devicesbelow.

For children under the age of 12 years with chronic asthma in whom treatment with an inhaledcorticosteroid (ICS) is considered appropriate, the least costly product that is suitable for anindividual child (taking into consideration technology appraisal guidance 38 and 10), within itsmarketing authorisation, is recommended.

For children under the age of 12 years with chronic asthma in whom treatment with an ICS andlong-acting beta-2 agonist (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 the individualchild is recommended.

These recommendations are from inhaled corticosteroids for chronic asthma (NICE technologyappraisal guidance 131).

NICE has written information for patients and the public explaining the guidance on inhaledcorticosteroids.



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Adults and children aged 12 and older

For adults and children aged 12 years and older with chronic asthma in whom treatment with aninhaled corticosteroid (ICS) is considered appropriate, the least costly product that is suitable foran individual, within its marketing authorisation, is recommended.

For adults and children aged 12 years and older with chronic asthma in whom treatment with anICS and long-acting beta-2 agonist (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 the individual isrecommended.

These recommendations are from inhaled corticosteroids for adults and children aged 12 andolder (NICE technology appraisal guidance 138).

NICE has written information for patients and the public explaining the guidance on inhaledcorticosteroids.

Inhaler devices for children aged under 5 years

For children under the age of 5 years with chronic stable asthma both corticosteroids andbronchodilator therapy should be routinely delivered by pressurised metered dose inhaler(pMDI) and spacer system, with a facemask where necessary.

Where this combination is not clinically effective for the child and depending on the child'scondition, nebulised therapy may be considered and in the case of children aged 3 to 5 years, adry powder inhaler (DPI) may also be considered.

Choice of device to be made within the pMDI and spacer range should be primarily governed byspecific individual need and the likelihood of good compliance. Once these factors have beentaken into account, choice should be made on the basis of cost minimisation.



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These recommendations are from inhaler devices for children aged under 5 years (NICEtechnology appraisal guidance 10).

NICE has written information for patients and the public explaining the guidance on inhalerdevices.

Inhaler devices for children aged 515 years

It is recommended that in addition to therapeutic need (including chosen drug and dose), thefollowing factors be taken into account when choosing inhaler devices for individual childrenwith chronic asthma:

the ability of the child to develop and maintain an effective technique with the specificdevicethe suitability of a device for the child's and carer's lifestyles, considering factors such asportability and conveniencethe child's preference for and willingness to use a particular device.

The general recommendations above should be taken into account when considering thefollowing specific guidance:

A press-and-breathe pressurised metered dose inhaler (pMDI) and suitable spacer deviceis recommended as the first-line choice for the delivery of inhaled corticosteroids as part ofregular planned daily therapy, with the aim of maximising benefits of preventive therapy inattaining good asthma control, and minimising potential systemic absorption. Whereclinicians believe that an individual child's adherence to the press-and-breathe pMDI andspacer combination is likely to be so poor as to undermine effective asthma control, otheralternative devices (taking account of the factors outlined in 1.1 and evidence ofequivalence of clinical effectiveness) should be considered, bearing in mind the need tominimise 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 ofasthma care that influence the effective delivery of inhaled therapy, including:

individual practical training in the use of the specific device



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monitoring of effective inhaler technique and adherence to therapyregular (i.e. no less than annual) review of inhaler needs, which may change over time withincreasing age.

These recommendations are from inhaler devices for children aged 515 years (NICEtechnology appraisal guidance 38).

NICE has written information for patients and the public explaining the guidance on inhalerdevices.

Quality standards

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

3. Written and personalised action plans

4. Inhaler technique

Resources

The following implementation tools are relevant to this part of the pathway.

Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12years and over: audit support

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

Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12years and over: costing report

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



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3 Difficult or severe asthma

Fractional exhaled nitric oxide measurement

Fractional exhaled nitric oxide measurement is recommended as an option to support asthmamanagement (in conjunction with the British guideline on the management of asthma 2012) inpeople who are symptomatic despite using inhaled corticosteroids.

This recommendation is from Measuring fractional exhaled nitric oxide concentration in asthma:NIOX MINO, NIOX VERO and Nobreath (NICE diagnostics guidance 12).

Omalizumab

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), andonly 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 compliancewith inhaled high-dose corticosteroids, long-acting beta2 agonists, leukotriene receptorantagonists, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate.

People currently receiving omalizumab whose disease does not meet the criteria above shouldbe able to continue treatment until they and their clinician consider it appropriate to stop.

These recommendations are from omalizumab for treating severe persistent allergic asthma(review of technology appraisal guidance 133 and 201) (NICE technology appraisal guidance278).

NICE has written information for patients and the public explaining the guidance onomalizumab.

Interventional procedures guidance

NICE has published guidance with special arrangements for consent, audit and clinicalgovernance on bronchial thermoplasty for severe asthma (NICE interventional procedureguidance 419).



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Quality standards


3. Written and personalised action plans

11. Difficult asthma

Resources

The following implementation tool is relevant to this part of the pathway.

Omalizumab for treating severe persistent allergic asthma (review of technology appraisalguidance 133 and 201): costing statement

4 Acute exacerbations

NICE has published quality statements relevant to people presenting with respiratory symptomsor exacerbations (see below).

Quality standards


6. Assessing asthma control

7. Assessing severity

8. Treatment for acute asthma

9. Specialist review

5 Follow-up

NICE has published a quality statement relevant to people who have received treatment for anacute exacerbation (see below).



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Quality standards

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

10. Follow-up in primary care



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Sources

Omalizumab for treating severe persistent allergic asthma (review of technology appraisalguidance 133 and 201). NICE technology appraisal guidance 278 (2013)

Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12years and over. NICE technology appraisal guidance 138 (2008)

Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12years. NICE technology appraisal guidance 131 (2008)

Inhaler devices for routine treatment of chronic asthma in older children (aged 515 years).NICE technology appraisal guidance 38 (2002)

Guidance on the use of inhaler systems (devices) in children under the age of 5 years withchronic asthma. NICE technology appraisal guidance 10 (2000)

Bronchial thermoplasty for severe asthma. NICE interventional procedure guidance 419 (2012)

Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VEROand Nobreath. NICE diagnostics guidance 12 (2014)

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after carefulconsideration of the evidence available. Those working in the NHS, local authorities, the widerpublic, voluntary and community sectors and the private sector should take it into account whencarrying out their professional, managerial or voluntary duties. Implementation of this guidanceis the responsibility of local commissioners and/or providers. Commissioners and providers arereminded that it is their responsibility to implement the guidance, in their local context, in light oftheir duties to avoid unlawful discrimination and to have regard to promoting equality ofopportunity. Nothing in this guidance should be interpreted in a way which would be inconsistentwith compliance with those duties.

Copyright

Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICEcopyright material can be downloaded for private research and study, and may be reproduced



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for educational and not-for-profit purposes. No reproduction by or for commercial organisations,or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

National Institute for Health and Care ExcellenceLevel 1A, City TowerPiccadilly PlazaManchesterM1 4BT

www.nice.org.uk

[email protected]

0845 003 7781



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Asthma Asthma Management

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