Asthma (Stable) - Management Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • The management of stable asthma

This guidance does not cover:

  • Acute presentation of Lower Respiratory Tract Infection.
  • Patients presenting with potential exacerbation of Asthma without prior diagnosis should be managed as per appropriate clinical guidance and an assessment and diagnosis confirmed during a period of stability
  • Children 12 years or under

Management

Goals of Asthma Therapy

To achieve complete control of Asthma Symptoms:

  • Maximise asthma control
    • no daytime symptoms
    • no night-time awakening due to asthma
    • no need for rescue medication
    • no limitations on activity including exercise
    • normal lung function
  • No exacerbation's
  • Minimise treatment side effects
Lifestyle Factors
  • Smoking is a major trigger factor for asthma and a significant cause of poor control, reducing exposure to cigarette smoke is essential.
  • Stop smoking advice and avoidance of tobacco smoke is vital - see smoking cessation care pathways
  • Manage gastro-oesophageal reflux & rhinitis as clinically appropriate, there is however, a lack of evidence that this will improve asthma control.
  • Weight reduction is recommended in obese patients to promote general health and to reduce subsequent respiratory symptoms consistent with asthma - See weight management pathways
Patient Education
  • Each patient should have a clear understanding of how to recognise and deal with deterioration in their asthma control.
  • A Personalised Asthma Control Plan is essential for ALL PATIENTS
  • Patients should have a basic understanding as to how their medication works, the importance of adhering to their medication regime and how to use their inhaler
  • Education should include personalised discussion of issues such as trigger avoidance and achieving a smoke-free environment
Rescue Medication
  • When providing an Asthma Control Plan consider the appropriateness of issuing oral steroids as rescue medication
  • Patients should be individually assessed for appropriateness of issuing rescue medication to keep at home and the decision based on patient understanding and previous history
  • Patients should be advised to contact a named Health Care Professional on commencing rescue medication and arrange to be reviewed within 2 days
  • Following appropriate education and with access to timely advice, rescue medication may be issued (prednisolone plain 5mg tablets - 40mg a day for 7 days)
  • Rescue medication should be considered in patients who have experienced severe attacks or who live in geographically isolated areas
  • Rescue medication should only be reissued following assessment of the patient
  • If patient is not suitable, ensure a system is in place and clearly understood by Practice staff, patient and carers, to allow access to rescue medication promptly following an assessment of symptoms.
Inhaler Devices
  • Prescribing by brand name is recommended to ensure the patient receives a consistent product see Asthma - Preferred treatment guidelines
  • Inhalers should only be prescribed after patients have received training in the use of the device and have demonstrated satisfactory technique.
  • The preferred inhaler therapies are based on:
    • Ease of use of inhaler device and acceptability to patient
    • Evidence of safety and efficacy from clinical trials
    • Cost
  • If the patient cannot use or declines the listed inhaler device, an appropriate alternative should be prescribed.
  • The choice of using a Dry Powder Inhaler (DPI) or Metered Dose Inhaler (MDI) depends on the patient's ability to use different inhaler devices and patient preference. In general, DPI devices are often easier to use than MDI devices.
  • A spacer device is recommended when using a MDI, particularly for patients prescribed ICS.
Prescribing tips
  • Use lowest effective ICS dose to achieve control.
  • Select the least costly product that is suitable for an individual, within its marketing authorisation.
  • Combination devices are recommended when ICS and LABA are required.
  • Review patients 6 weeks after making any treatment change (up or down titrating)
  • Step up and step down according to asthma control – using objective measures to aid eg. Asthma Control Test (ACT)
  • See pharmacology guidance for more detailed information
Safety Considerations
  • All patients on high doses of ICS (≥1000 micrograms Beclometasone dipropionate BDP equivalent per day) should be made aware of the risks and given an ICS safety warning card. For further information and equivalent steroid potencies click here see Pharmacological Management of Stable Asthma.
  • Patients taking nasal corticosteroids in addition to inhaled corticosteroids should be assessed individually. For example, a patient taking a dose of ICS between 800‐1000 micrograms of BDP equivalent per day and nasal corticosteroids, a steroid treatment card is recommended.
  • Ensure processes are in place to ensure patients can be seen quickly in event of deterioration and when rescue medication is commenced
  • Patients should never be prescribed LABA (or LAMA) as monotherapy
Sub optimal (poor) control: any of the below criteria
  • Using reliever more than 3 times weekly
  • Symptomatic more than 3 times weekly
  • Waking one night a week
  • Two or more courses of rescue oral steroids in past 12 months
  • 12 or more reliever (ie salbutamol) in past 12 months
  • ACT score less than 20
Inhaled corticosteroid (ICS) therapy risks:
  • High dose ICS (1600mcg/day beclometasone equivalent or Fluticasone1000mcg/day) is associated with a greater risk of systemic side effects including adrenal suppression, decrease in bone mineral density, cataracts and glaucoma, diabetes mellitus and adverse psychological and behavioural effects.
Increasing treatment:
  • Before initiating new drug therapy or stepping up check:
    • Concordance with existing therapy
    • Inhaler technique
    • Trigger factors
  • A rescue course of steroids may indicate the need to increase regular treatment to the next step
Reducing treatment:
  • Step down should be considered:
    • After 12 weeks if control is achieved (and after every subsequent 12 week period).
    • If control is maintained, therapy should be reduced (dose decreased by 25-50% each time) to the lowest step that maintains control.
    • When on combination ICS & LABA, the preferred option is to reduce does of ICS by 50% while continuing LABA. If control is maintained further reductions in ICS should be made until on a low dose, when the LABA may be stopped.
    • After stepping down review in 12 weeks and step up again if symptomatic

Referral

  • Referral Criteria
  • Referral to Secondary Care
    • If tests not available in primary care
    • If Diagnosis unclear
    • If suspected occupational asthma (symptoms that improve when patient is not at work, adult onset asthma and workers in high-risk occupations, worsening since change in work)
    • If poor response to asthma treatment
    • Following severe/life-threatening asthma attack

Referral Instructions

  • e-Consultation is available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Please support the development of a personalised Asthma Control Plan to support shared decision making and self care

Patient information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 03.2019
  • Ref No: RS4 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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