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GPs go forth

Confusion over asthma diagnosis as 'gold-standard' guidelines contradict NICE

Respiratory experts have set out revised ‘gold-standard’ guidelines contradicting NICE experts on how best to diagnose asthma, potentially leaving GPs with conflicting sets of advice.

In a draft revision of their asthma guidelines, the British Thoracic Society (BTS) and Scottish Intercollegiate Network (SIGN) have stuck with their previous advice, which allows GPs the option to base a diagnosis on a trial of treatment in patients with suspected asthma

This has effectively snubbed NICE plans to make sure GPs only make a diagnosis of asthma following a battery of objective tests. 

GP asthma experts involved in BTS/SIGN told Pulse their guidelines were deliberately intended to be more ‘pragmatic’ and ‘practical’ than the NICE guidelines.

However, NICE insisted the two sets of guidelines did not differ ‘substantially’.

BTS/SIGN guidelines advisor Dr Hilary Pinnock, a practising GP and academic at the University of Edinburgh, told Pulse the revised version builds on its existing guidelines that recommended that a positive response to a trial of therapy is enough for GPs to make a diagnosis for patients at high risk – provided they record their reasoning.

Asked about the disparity with NICE regarding trials of therapy, Dr Pinnock said the BTS/SIGN guidance ‘is intended to be more pragmatic, and in an area with a limited evidence base aims to provide a practical approach for clinicians’.

She added that the BTS/SIGN guidelines panel had not only reviewed the data on specific tests, but also taken into account ‘pragmatic studies that evaluated tests and algorithms in clinical practice’.

The guidelines updates were mainly aimed at raising GPs’ awareness that ‘asthma is a variable condition’ and that ‘there is no absolute test for confirming or refuting asthma’, Dr Pinnock said.

GP experts said the BTS/SIGN decision raised further questions over NICE’s approach.

Dr Steve Holmes, RCGP lead on respiratory medicine, said NICE had taken ‘a predominantly scientific approach based on - as they clearly highlight - often low or moderate quality research’.

He added: 'NICE extrapolated to suggest a diagnosis of asthma should not be made in primary care unless we have reversibility spirometry and an elevated FeNO. Whereas the BTS/SIGN draft recognises that there is enormous variation among people in the way their asthma presents and a good clinician balances the science with more of a clinician's artistic skills and experience to draw the full picture of the patient’s condition and do what is best for the patient.’

Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, said it was ‘refreshing to see the uncertainty GPs are familiar with recognised in official guidance’ and that the recommendations were ‘a welcome balance to some of the more entrenched views that have been aired in the general media recently concerning asthma diagnoses’.

He added that it was ‘quite acceptable for GPs in England and Wales to base their clinical practice on SIGN guidance should they find it useful, for diseases recognise no national boundaries, and no one organisation holds a monopoly on the truth’.

But Dr Kevin Gruffydd-Jones, a GPSI in respiratory medicine in Bath, told Pulse he disagreed with SIGN’s ‘pivotal role’ for a trial of therapy, which he said ‘lacks an evidence base’ and that the ‘discrepancy between the two sets of guidelines needs to be resolved’.

A NICE spokesperson said: ‘We do not believe there is anything in the proposed updates to the BTS-SIGN guideline which substantially contradicts the NICE draft guideline on asthma diagnosis.’

NICE focuses on objective testing

spirometry COPD ten top tips  PPL

BTS/SIGN guidelines on asthma have up to been widely recognised as the ‘gold standard’ guidelines for GPs to follow.

However, NICE last year set out plans to introduce its own guidelines on diagnosis and monitoring of the condition, claiming that evidence had shown up to a third of patients with asthma may have been misdiagnosed, and advising that GPs would in future have to carry out spirometry and bronchodilator reversibility tests, and in some cases FeNO breath tests, in order to confirm a diagnosis in anyone over the age of five.

However, the plans were heavily criticised by GP leaders who questioned the basis for using certain tests and warned they would force GPs to refer large numbers to specialist clinics.  NICE has since taken the unprecedented step of putting the guidelines on hold, until the recommendations have been piloted at practices around the country.

Click here to read how the two sets of guidance differ




Readers' comments (13)

  • Too many guidelines.

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  • Dear GPSI in respiratory medicine,
    How can a therapeutic trial of a medicine in a patient "lack an evidence base"?
    Someone needs to get out a bit more.
    Paul C

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  • Bang their heads together.
    I'll carry on practising as I always have unless they can reach consensus and back it up with some pretty hefty evidence.

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  • PS Paul Cundy
    Well done - nail firmly hit on the head!

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  • So what about those patients that get a little wheezing / reversible airways (subjectively improved with B2 agonist inhaler) ONLY with hayfever or during a nasty chest infection?

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  • 10.54 gp partner is right.

    My mother had mild asthma and when she had pneumonia in hospital she needed ventolin and treatment for her asthma which became much worse. We bought her inhaler in and it really helped her for a while as she was really struggling due to the pneumonia which made her asthma much more severe.

    Unfortunately the consultant in ITU in a major london teaching hospital would not accept she had asthma and deliberately stopped her asthma treatment.

    This was despite being shown her gp prescribed ventolin and being told by me, a doctor, she needed it and that her gp had been assessing and treating her mild asthma symptoms successfully by himself for over a decade.

    Also a consultant collegue at the same hospital who knew my mother well as a friend for years and knew she had mild asthma for years tried to get my mothers consultant to put her back on asthma meds that she had been taking regularly.

    However her consultant stopped all her asthma treatments as he would not accept she had asthma only giving the excuse that as my mum had not been seen in hospital for asthma, just in the gp clinic.

    She died shortly afterwards.

    So what about this group of patients whose mild asthmatic symptoms which are completely controlled with beta 2 blockers by their gps who are worsened with pneumonia or other triggers?

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  • Anon 11:30am. Not Beta Blockers unless you wish to cause premature demise of patient.

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  • You are right 12.17, it was ventolin. I just am still upset about it all of 8 years later.

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  • Vinci Ho

    (1) ventolin/salbutamol is short acting beta-2-agonist
    (2) Typical response when an establishment is embarrassed in public:There is a difference between the two sets of guidances, Mr NICE , it is called NICE being persecutory in tone and slagging off a common sense driven approach by GPs . BTS/SIGN has respected the artistic spirit of practising medicine
    (3) Nobody said FeNO and spirometry are not important but the spirit of medicine as we always teach our youngsters : History-Examination-Investigatons . So often investigations are there to AID our ability of making diagnosis . Reality and practicality are also something for those trapped in ivory tower to learn
    (4)The current draft on management of back pain is also receiving similar criticism.....

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  • Delayed guidelines? Yay, we can get on with history taking...any tests are there to support diagnosis not define it. Oh, and better not confuse the “gold-standard” bit with the GOLD vs NICE for COPD folks.

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