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GPs buried under trusts' workload dump

NICE reverses position on inhaled steroid doses in children with asthma

There is no evidence for increasing inhaled corticosteroid (ICS) doses in children experiencing asthma exacerbations, NICE has said in a draft update of its asthma guidance, a reversal of its previous position.

The update removes the 2017 recommendation to consider quadrupling the regular dose of ICS in children who experience a deterioration, as there is no evidence of clinical benefit from increasing the dose.

The replacement recommendation says that patients should be educated on what to do if control deteriorates, including contacting a healthcare professional for review. It says that patients should be encouraged to use their ICS consistently to avoid worsening symptoms and to remind patients that there is no evidence of clinical benefit from increased doses of ICS.

NICE said in the draft update that ‘the evidence for children and young people found that increasing the dose of ICS did not show any benefits or harms compared to the usual dose for reducing asthma exacerbation’.

It also said that children who found increasing their dose useful should be able to do so as part of an agreed self-management plan, but that if children did experience exacerbations, they should be reviewed by a healthcare professional to review their action plan and inhaler technique.

NICE commented: ‘The recommendation will lead to an increase in the review of self-management programmes for children and young people and reduce the variation in current practice for this. The increase in resources needed for this is likely to be offset by a reduction in the cost of treating asthma exacerbations.’

The draft recommendation update is currently out for consultation until 27 November.

A study published last year found that temporarily quadrupling the dose of ICS during an exacerbation could help to prevent a severe asthma attack, but this included mostly adults and researchers said that the magnitude of risk reduction was smaller than expected.

Earlier this year, NICE announced that it would collaborate with BTS/SIGN to produce a single set of asthma guidance to alleviate confusion for GPs. 

NICE was criticised by GPs when its asthma guidance was originally published in 2017 recommending FeNO testing as an objective test for asthma in primary care, despite many GPs not having acces to the test.

Readers' comments (8)

  • No evidence does not mean it does not work. What do we do in exacerbations? Give more steroids.

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  • As ever, savings on prescribing costs will give a warm glow, perhaps tempered by the unresourced extra time spent reviewing these patients, offering them exactly what? NICE needs to add to the pressure to divert resources/finance from system savings to the teams doing the work....do PCNs need to make up yet more 'clinics' to extract the money??

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  • So the advice is not to increase inhaled steroids unless increasing inhaled steroids works and see your GP to update your management plan that might include increasing inhaled steroids but probably not leaving no clear management strategy except hoping that good inhaler technique will prevent exacerbations ... brilliant!

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  • ‘The increase in resources needed for this IS LIKELY to be offset by a reduction in the cost of treating asthma exacerbations.’ NICE

    So you’re GUESSING? and really don’t give a fx?

    Try that in clinical practice and you will ‘guess your way’ to the GMC.

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  • Copperfield help us out here ; we seem to have gone all Kafka

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  • There was a paper in the BMJ about 20years ago . “ increasing inhaled steroids in exacerbations of childhood Asthma didn’t help”

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  • "The increase in resources needed for this is likely to be offset by a reduction in the cost of treating asthma exacerbations."
    This is category D- or E- based guidance : conjecture at the whim of a self-styled specialist who does not work in GP.
    It is rubbish.
    The supposed savings will not be in same budget as the additional costs, so cannot be 'offset' at all - ask a real accountant!
    In fact the proposal is that GPs spend more time giving patients a 'self-management plan' which requires them to seek GP contact before trying anything else, like, maybe increasing their inhalers : and this will result in more of them being given soluble steroid tablets (expensive), super-duper extra inhalers or oral medications (expensive), and also more antibiotics (like other countries do), and in the meantime they will either use much more SABA, or go to A&E in addition for nebulising.
    So where exactly will there be a saving?
    not drugs, not GP time, not AE time, maybe in lives lost, hence costing the NHS less to keep them alive?

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  • Repeated flip flops from Nice and often pitifully inadequate evidence used to justify guidance. Familiarity breeds contempt.......

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