GPs should carry out objective testing to diagnose suspected asthma, rather than simply relying on symptoms, suggest new guidelines from NICE published today.
The new guideline recommends spirometry and forced exhaled nitric oxide (FeNO) testing are used by GPs – where available – alongside the usual clinical assessment of symptoms, saying it will make diagnosis more accurate and treatment more effective.
The guideline rejects the recommendations from recently updated gold-standard BTS/SIGN guidelines to confirm a diagnosis of asthma based on a trial of treatment.
It also recommends adding an leukotriene receptor antagonist (LTRA) tablets as the first-line add-on therapy for patients whose asthma is not controlled on inhaled steroids alone, as it claims they are are cheaper and therefore more cost-effective.This diverges significantly from the BTS/SIGN recommendation to offer a long-acting beta agonist (LABA) first.
NICE said its initial draft diagnostic recommendations were designed to tackle the third of patients which could be misdiagnosed with asthma. But it met with harsh criticism from both the BMA and the RCGP when first published in in 2015 on the basis that they were too complex and would lead to increased GP appointments, referrals and costs.
In addition, respiratory experts voiced concern over the addition of LTRAs to treatment guidelines, saying that it could ‘cost lives’ as patients may neglect their steriod inhalers.
In response, NICE took the unprecedented step of delaying publication of the guidelines to pilot the changes and discuss their implementation with NHS England.
A recent study did find that spirometry testing was ‘useful’ for asthma reviews in children in primary care, but GP experts say NICE’s approach is ‘not fit for purpose’.
Dr Dermot Ryan, GP and president of the international Respiratory Effectiveness Group, told Pulse the guideline was ‘setting GPs up for failure’.
He said: ‘It is really important that patients with asthma receive a proper diagnosis but the overconcentration on one parameter – in this case FeNO – is neither here nor there. Most GPs don’t have access to FeNO and most CCGs don’t have the funds or the know-how to invest in it.’
He went on to suggest that the guideline was ‘being done purely for cost minimisation’ adding: ‘This should be resisted and it won’t save money. It’s not for no reason that guidelines elsewhere in the world recommend a LABA as the first add-on to inhaled corticosteroid. Really this guideline is not fit for purpose.’
Dr Duncan Keeley, GP and policy lead for the Primary Care Respiratory Society, said they were ‘concerned at the potential for confusion’.
He said: ‘NICE is an excellent organisation, but PCRS UK has always questioned the wisdom of seeking to replace the widely respected BTS / SIGN guideline for asthma – which was itself approved by NICE. We identified major potential difficulties in implementation of the recommendations in the NICE guideline – views shared by many other organisations in the respiratory field – and we advised against its publication.
‘We would encourage NICE and BTS/SIGN to cooperate on a single guideline in future. We will provide advice in the meanwhile to the primary care community about how to reconcile the conflicting guideline advice that we now have.’
The NICE guideline does acknowledge that it recommends a ‘significant enhancement to current practice, which will take the NHS some time to implement’.
It adds: ‘The investment and training required to implement the new guidance will take time. In the meantime, primary care services should implement what they can of the new guidelines, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.’
BMA GP Committee prescribing lead Dr Andrew Green said the new NICE guidance on asthma was a ‘significant change’, but it was pleased that both NHS England and NICE recognise additional investment was be required to make these changes happen with diagnostic facilities in ‘local hubs’.
He added: ‘Their statement that GPs should continue with current diagnostic methods during the transition period is vital both to protect GPs and to ensure system stability.’
RCGP Clinical Innovation and Research Centre joint medical director Dr Imran Rafi said: ‘We still have concerns about the capacity, cost and training implications of implementing FeNO testing as standard in general practice – in this respect it is encouraging that the guidelines include the caveat that this is unlikely to be implemented until GPs are appropriately resourced to deliver it.
‘There is also the issue that the addition of Leukotriene Receptor Agonists (LTRAs) as a treatment could lead to patients inadvertently stopping their use of inhaled corticosteroids, particularly when not prescribed as a combination inhaler with long-acting bronchodilators. Patients will need to be reminded about this.’
Dr Rafi added that it was ‘important to remember that they are not tramlines and GPs must retain the freedom to develop treatment plans based on the unique circumstances of the patient in front of us’.