Primary Care Guidelines by Juan Fernando Florido Santana

January 01, 2025 Podcast - The Asthma Revolution Part 3: New Treatment Advice for Ages under 12

The video version of this podcast can be found here:

· https://youtu.be/4sbHjioaudI

This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on diagnosing, monitoring, and managing chronic asthma, NG245, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode I will just focus on treating asthma in children aged 5 to 11, and those under 5

If you haven’t already, I recommend checking out the previous two episodes on this subject covering “initial assessment and diagnosis” and the “asthma treatment in patients aged 12 and over”

In the next episode, we will finish the guideline by covering:

And finally, Asthma monitoring, general treatment principles, and management in special groups

The new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you can find a link to it in the episode description.

I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.

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There is a podcast version of this and other videos that you can access here:

Primary Care guidelines podcast:

· Redcircle: https://redcircle.com/shows/primary-care-guidelines

· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK

· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148

There is a YouTube version of this and other videos that you can access here:

The Practical GP YouTube Channel:

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The link to the new collaborative NICE guideline on chronic asthma can be found here:

· https://www.nice.org.uk/guidance/ng245

The table on alternative diagnoses in wheezy children in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

· https://rightdecisions.scot.nhs.uk/bts-nice-and-sign-asthma-pathway/diagnosis/alternative-diagnoses-in-wheezy-children/

The table on alternative diagnoses in adults in the BTS/SIGN British guideline on the management of asthma SIGN 158 can be found here:

· https://rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/diagnosis/alternative-diagnoses-in-adults/

The algorithm A for a summary of objective tests for diagnosing asthma in adults and young people (aged over 16 years) with a history suggesting asthma can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/bts-nice-and-sign-algorithm-a-summary-of-objective-tests-for-diagnosing-asthma-pdf-13556516365

The algorithm B for a summary of objective tests for diagnosing asthma in children aged 5 to 16 with a history suggesting asthma can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/algorithm-b-objective-tests-for-diagnosing-asthma-in-children-aged-5-to-16-with-a-history-pdf-13556516366

The algorithm C for a summary of the pharmacological management of asthma in people aged 12 years and over can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

The algorithm D for a summary of the pharmacological management of asthma in children aged 5 to 11 years can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/algorithm-d-pharmacological-management-of-asthma-in-children-aged-5-to-11-years-bts-nice-sign-pdf-13556516368

The algorithm E for a summary of the pharmacological management of asthma in children under 5 can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/algorithm-e-pharmacological-management-of-asthma-in-children-under-5-bts-nice-sign-pdf-13556516369

The MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast can be found here:

· https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions

The table of inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline can be found here:

· https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029

The NICE guideline on air pollution: outdoor air quality and health can be found here:

· https://www.nice.org.uk/guidance/ng70

The NICE guideline on indoor air quality at home can be found here:

· https://www.nice.org.uk/guidance/ng149

Disclaimer:

The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions.

In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido.

Transcript

If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new guideline on diagnosing, monitoring, and managing chronic asthma, focusing on what is relevant in Primary Care only. Given how extensive the guidance is, in this episode we’ll just focus on treating asthma in children aged 5 to 11, and those under 5

If you haven’t already, I recommend checking out the previous two episodes on this subject covering “initial assessment and diagnosis” and the “asthma treatment in patients aged 12 and over”

In the next episode, we will finish the guideline by covering:

And finally, Asthma monitoring, general treatment principles, and management in special groups

So, stay tuned for this!

Right, let’s jump into it.

As you probably know, the new guideline is a collaborative initiative developed by NICE, the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN). It replaces previous guidance, and you’ll find a link to it in the episode description.

As we are going to look at the pharmacological management, it is worthwhile remembering that, from a treatment perspective, there are 3 groups of patients:

· Those aged 12 and over

· Those aged 5 to 11 and

· Those aged under 5

NICE has produced summaries of the pharmacological management in the various age groups and a link to them can be found in the episode description.

And today, we are going to focus on the pharmacological management in children so we will start with those aged 5 to 11.

You may be aware that short acting beta 2 agonists or SABAs have disappeared from the management of patients aged 12 and over. But in children under 12, SABAs have certainly a role to play, so let’s have a look at it.

And, as the initial management in children aged 5 to 11 with newly diagnosed asthma, we will offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with a short-acting beta2 agonist (or SABA) as needed.

By the way, for guidance on what paediatric doses of inhaled corticosteroids are considered low, moderate and high, NICE, SIGN and BTS have produced tables showing the various inhaled corticosteroids and their different doses that you can refer to. You can find a link to them in the episode description.

Now, what do we do after this, that is, if asthma is not controlled with this regimen?

In this age group, there are two pathways: a MART pathway and a conventional pathway. Let’s look at the MART pathway first.

Here, we will consider paediatric low-dose MART when asthma is not controlled on paediatric low-dose ICS plus SABA as needed, as long as they are assessed to have the ability to manage a MART regimen. The current evidence supporting the use of MART in children aged 5 to 11 is based on the use of a dry powder inhaler.

Then, if asthma is not controlled on paediatric low-dose MART, we will consider increasing to paediatric moderate-dose MART. That is also straightforward.

Alternatively, the conventional pathway is needed when children are assessed as being unable to manage the MART regimen. Here, we would consider adding a leukotriene receptor antagonist (LTRA) to twice daily paediatric low-dose ICS plus PRN SABA when asthma symptoms are not controlled. We will give the leukotriene receptor antagonist for a trial period of 8 to 12 weeks, then stop it if it is ineffective. And again, we will follow the MHRA advice on the risk of neuropsychiatric reactions in people taking montelukast

Then, if their asthma symptoms are not controlled on a paediatric low-dose ICS plus PRN SABA (with or without a leukotriene receptor antagonist depending on previous response), we will offer a twice daily paediatric low-dose ICS/LABA combination inhaler plus PRN SABA.

Then, if their asthma symptoms are not controlled on paediatric low-dose ICS/LABA plus PRN SABA, we will offer a twice daily paediatric moderate-dose ICS/LABA inhaler plus PRN SABA (again, with or without a leukotriene receptor antagonist depending on previous response).

In summary, the conventional pathway recommends that we try both a leukotriene receptor antagonist and a LABA before increasing the inhaled corticosteroid to a moderate dose. In other words, the only time that we will prescribe a moderate dose inhaled corticosteroid to children aged 5 to 11 will be alongside a LABA, either with or without a leukotriene receptor antagonist depending on the case.

But how do we decide whether to use a MART regimen or a conventional pathway?

We need to start by saying that the guideline specifically supports the use of the MART regimen for children under 12 unless assessed as being unable to manage it. This is to address concerns that younger children may have difficulty understanding the MART regimen, which can lead to confusion about when to take the inhaler for maintenance versus symptom relief. This may lead to confusion between maintenance and reliever doses, potentially leading to inconsistent dosing and both overuse or underuse of the inhaler.

But, how do we make this assessment?

Well, the decision to use MART should be based on factors like:

· The child’s ability to understand the regimen and use the inhaler correctly.

· The risk of overuse or underuse and

· The overall safety and suitability for the individual child.

Why do we mention safety? Well, we need to be aware that most of the robust studies on MART have been conducted in adults or adolescents (that is, 12 years and older) and there is limited evidence to support the safety and effectiveness of MART for children under 12. And there is also licensing reality because, at the time of publishing this guideline and releasing this episode, no asthma inhalers were licensed for MART in children under 12, so this use would be off-label. Although off-label prescribing is permissible in the UK when it's based on sound clinical judgement and informed consent, this approach requires careful consideration and clear communication with parents or guardians and we would have to be comfortable with it.

Despite these considerations and in one sentence, the take-home message is that NICE recommends MART for children under 12, provided they are deemed suitable using our clinical judgement.

And regardless of the pathway that we have chosen, if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without a leukotriene receptor antagonists), we will refer them to a specialist. In other words, we will not prescribe high doses of inhaled corticosteroids to children aged 5 to 11 without seeking specialist advice first.

Let’s now look at the pharmacological management in children under 5

And these recommendations are for children under 5 with both newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment.

So, if there are:

symptoms that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or if there are
severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids)

Then the first step is to consider an 8 to12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [or SABA] for reliever therapy).

If symptoms do not resolve during the trial period, we will check:

the inhaler technique and adherence to treatment
possible environmental sources of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution) and
we will check possible alternative diagnosis.

And if we cannot explain the poor response to treatment, we will refer to a specialist. This means that we will not increase the inhaled corticosteroid to a moderate dose if there has not been a good initial response to a low dose first.

However, if symptoms are resolved, we will consider stopping treatment after 8 to 12 weeks and then review the symptoms after a further 3 months.

Then, if symptoms resolve during the trial period, but then:

symptoms recur by the 3-month review, or
the child has an acute episode requiring systemic corticosteroids or hospitalisation, we will restart regular inhaler corticosteroids, beginning at a paediatric low dose but here we will be able to titrate up to a paediatric moderate dose if needed, also with a SABA when needed. When symptoms settle, we will consider a further trial without treatment after reviewing the child within 12 months.

If symptoms are not controlled on a paediatric moderate dose of an inhaled corticosteroids as maintenance (with SABA as needed), we will consider a leukotriene receptor antagonist (LTRA) in addition to the inhaled corticosteroids. We will give the leukotriene receptor antagonist for a trial period of 8 to 12 weeks, and we will then stop it if it is ineffective.

If symptoms remain uncontrolled on a paediatric moderate dose of inhaled corticosteroids as maintenance and a trial of a leukotriene receptor antagonist has been unsuccessful or not tolerated, we will stop the leukotriene receptor antagonist and refer the child to a specialist for further investigation and management.

On the other hand, if asthma symptoms are completely controlled and we may want to consider decreasing maintenance therapy.

In this case, at annual review, we will discuss the risks and benefits of decreasing their maintenance therapy and we will update their asthma action plan and arrange self-monitoring and follow up.

When decreasing maintenance therapy, we will:

Stop or reduce the dose of medicines in an order that takes into account the clinical effectiveness when they were first introduced, as well as their side effects and the patient’s preference.
We will allow at least 8 to 12 weeks before considering a further treatment reduction and
If we are considering step-down treatment for people aged 12 and over on a low-dose maintenance inhaled corticosteroid (ICS) plus a SABA as needed or a low-dose MART, we will step down to on demand AIR therapy with a low-dose ICS/formoterol combination inhaler

So that is it, a review of the treatment of asthma in patients aged under 12.

We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.

Thank you for listening and goodbye.

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