Draft update of the SIGN/BTS British guideline on the management of asthma

Comments on Scottish Intercollegiate Guideline Network (SIGN)
DRAFT UPDATE OF THE SIGN/BTS BRITISH GUIDELINE ON THE MANAGEMENT OF ASTHMA

The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the call for comments on the draft update of the SIGN/BTS British Guideline on the Management of Asthma.

General Comments:

The College has asked Fellows with relevant expertise to scrutinise the amended guideline and their overall impression is that it reads well, is laid out in a logical fashion and provides clear direction and practical guidance.

The new additional segments enhance the document, bringing it in line with current practice and reflecting the new developments in this field over the last 10 years. Ultimately reminding that stepping down treatment is also a priority.

Specific Comments:

1. Section 2.4: Reference to occupational asthma welcome – improvement on previous guideline.
2.           Section 3: Non Pharmacological 3.1.1: evidence base does seem to sit on the fence and is against common sense popular advice re: avoiding pets, cats, dogs, HDM.
3. Section 3.1.9: A welcome addition – needs to be emphasised given increasing issue with obesity rising.
4. Section 3.2.1: avoidance of HDM and methods to do this although not evidence based does seem common sense, may be controversial.
5. Section 3.2.8; good advice.
6. Section 3.2.13: Good clarification of this point.
7. Section 4.2.1: Table 8B – Relvar under criticism currently – and should be reviewed for inclusion. It has not been recommended for some formularies until the confusing name and colour of device is addressed – controversial GSK drug currently. Also there is no mention of flutiform which is being very widely used for asthma now and may be important to add to the table.
8. Section 4.3.2: LABA prioritised appropriately – clear steps in-line with BTS current guidance. Long-acting muscarinic antagonists are useful at this level but do not have a license for use and it is presumed this is the reason that they have not been added to the summary. However they are added to 4.4. What is the difference in approach?
9. Section 4.3.2:  will anti muscarinics eventually come in at an earlier step than after oral b agonists? For example after leucotrienes – but these are not yet licensed.  This is under review and most Respiratory Physicians may try this with non responders.
10. Section 4.5.4: The OMLAZIMUB section was well covered previously but there may now be more outcome data.  Advice re: discontinuation of therapy may be useful.
11. Section 4.5.5:  Immunotherapy not recommended – gives clarity to this issue.
12. Section 4.5.6: Bronchial thermoplasty – Practical advice should probably include reference to assessment in tertiary referral centre specialist thermoplasty clinic prior to Rx to ensure the most appropriate patients only progress to treatment.
13. Section 4.7.6: GORD point interesting – generally controlling acid reflux to lung seems a good idea to avoid triggering asthma or fibrotic change.
14. Section 5.4: patient must have any new device assessed for suitability – a major issue with switchovers to cheaper devices with different delivery device and patient unable to use them – very supportive of this statement as devices cannot simply be given by a change of prescription with no consultation with the patient!
15. Section 5.4: the concept of establishing which device a patient is most competent with is paramount and where possible stick to that delivery device.
16. Section 6.1 NRAD – has reported – assume this will be updated.
17. Section 6.3.5: Magnesium Advice Concise – and clear to limit to 1 dose to avoid muscle fatigue.
18. Section 6.3.7: Acute exacerbations, no indication for leukotriene inhibitors.
19. Section 6.3.12: “Anaesthetists and Intensivists should be contacted if there is no improvement in or indeed a deterioration” - this sentence may be better placed immediately after the bullet points and before the references to deteriorating patients.
20. Sections 6.7 – comments restricted to adult patients.
21. Section 7.2.1: Psychosocial factors and poor adherence/compliance are major issues – this is a very important statement and should be included – probably major modifiable factor.
22. Section 9.2: maternal death levels highlight the importance of avoidable deaths and should encourage the use of standard asthma Rx in pregnancy.
23. Section 9.3.5: Leukotrienes are safe – paramount issue is maintaining asthma control in pregnancy.
24. Section 9.3.7: Omlazimub – no evidence of contra indications in pregnancy as yet but caution is advisable.
25. Section 10.3: Occupational Asthma – additional signposting useful.
26. Section 10.3.1: Sensitivity and specificity – evidence base explained accurately - with specific instruction.
27. Section 10.3.2: IgE testing for high molecular weight substances only – emphasis is helpful.
28. Section 10.3.4: Provocation Testing – unaware of evidence or common practice on this.
29. Section 10.3.5 Sputum Eosinophilia - not routinely available in DGH.
30. Section 10.3.6 FENO well accepted.
31. Section 11.1 Care Pathways – reads well although the evidence base is limited – generally accepted that care pathways/bundles/multidisciplinary teams/MCN’s/Quoffs/Specialist Clinics in Primary and secondary care/disease registry/Specialist Nurses improve care.
32. Section 11.2: Educating Physicians – seems like common sense - American/ NZ/Australian evidence supports this.
33. Section 11.3: Specialist Asthma Clinics – for difficult asthma probably required and prioritising those with psychosocial issues.
34. Section 11.4: Telehealth have had direct experience with this – for severe recurrent admissions and difficult cases with frequent non severe presentations this has helped reassure them on a psychosocial front.
35. Section 11.6: Ethnicity – needs to be handled delicately – less likely to attend but need extra education/input.
36. Section 11.7: Lay Led statement is supported with respondents also reporting examples of negative outcomes.
37. Section 11.8: Pharmacists could be an ideal point of contact for education, compliance, assessment of device – directly observing technique, involved in any device switching.
38. Section 12: Self-management: PAAPs are crucial – empower patients.
39. Section 12.4: Primary and Secondary Care important – tailor to individual patients circumstances.
40. Section 12.5: Adherence /Compliance/PAAP’s….most important issues to gain control.
41. Section 13: Access to care and information - nicely summarised, signposting all stakeholders is important.