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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.
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].
Managing asthmaManaging asthma NICE Pathways
1 At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children
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:
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
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.
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose
of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA2
in combination with the ICS.
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose
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
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.
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).
See principles of care [See page 3] for information on ICS doses.
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
devices [See page 12].
NICE has written information for the public on inhaled corticosteroids for the treatment of
chronic asthma in children under the age of 12 years.
The following recommendations are from NICE technology appraisal guidance on inhaled
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.
For adults and children aged 12 years and older 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 is recommended.
These recommendation should be read in conjunction with the recommendations in inhaler
devices [See page 12].
NICE has written information for the public on inhaled corticosteroids for the treatment of
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.
Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over)
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
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.
See principles of care [See page 3] for information on ICS doses.
Inhaled corticosteroids and long-acting beta-2 agonists for person aged 12 or over
The following recommendations are from NICE technology appraisal guidance on inhaled
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.
For adults and children aged 12 years and older 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 is recommended.
These recommendation should be read in conjunction with the recommendations in inhaler
devices [See page 12].
NICE has written information for the public on inhaled corticosteroids for the treatment of
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)
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
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
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.
See principles of care [See page 3] for information on ICS doses.
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
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