Asthma Guidelines: What's new?

Music. Welcome to Primary Care Analysis Boost. You're here with Dr Sarah Bechtelma and Dr Lisa Adams.

And we're here talking to Dr Marageshrin Raja who is a GP and a clinical lead for respiratory in Greater Manchester and he's going to talk us through all the new changes in the new guidelines from November 2024 for asthma for children and adults. Yes exactly and we go through the different recommendations for all people over 12 to adults as well as some of the younger groups.

We discuss changes um that have been made by these guidelines we go through a reminder of what symptoms make up a typical asthma history before talking about pheno and spirometry peak flows blood tests and things like eosinophils and ig house dust mite um testing it's a it's a comprehensive list of things that we're looking at so yeah and then we move on to management changes so um the massive need to avoid over reliance

on saba salbutamol inhalers and what air and mart therapy are and why you might use each and focusing mainly on adults in this section. And then finally, we touched on some issues around green prescribing and things like steroid cards and other elements in management interviews and things like adherence and inhaler technique importance.

It's a really good overview of the new guidelines, really comprehensive, really concise. So we hope that you enjoy. So Raj, if we start with introductions, if that's all right with you. So I'm hi Sarah so thank you for having me so I'm Murugesun Raja I'm a GP at Horton Medical Centre which is part of Hope Citadel and I also work as the clinical lead for respiratory medicine for NHS Greater Manchester Strategic Clinical Network and also as the Associate Medical Director for the NHS GMICB.

Brilliant it's lovely having you here so we thought we'd get you on for an update on the new asthma guidelines um they um they changed was it november that they did the huge joint guideline with nice bts and science so everyone everyone combined and it's both children and adults that they've they've changed will you tell us a bit about why they've changed it and what they've updated to start us off yep so like you said you know previously nice guidelines bts guidelines sign

guidelines were all different and there was always each of them were challenging each other. So the task was to actually bring them all together. So this was a mammoth effort for nice colleagues, for BTS colleagues, as well as science colleagues to come together, and they all worked together to actually come to something that they can all agree with. So this guideline is kind of a...

A marker on the sand in the sense to kind of put a rest to all those dialogues in the past and then move towards a probably unified future we're managing asthma for at least in the UK for us yeah because I think in the past you've kind of cherry-picked like oh well the sign one says this so I think the way that you know the the nice committee was all formed because they were, they were challenging BTS was challenging nice and then nice was challenging BTS it was just you know why can't

we just come together yeah and make a guidance together and that's what's happened it was brilliant yeah we're all on the same page yeah um we're going to ask you a little bit in more detail about what exactly has changed but um can you give us a little bit of a brief introduction as to maybe what the big hitters were that have changed with the combined guideline now yeah so other than bringing them all together it covers diagnosing so we're able to kind of get an accurate diagnosis in asthma

because previously we always struggled with the different guidelines saying different things, but now we'll have one consistent way of diagnosing asthma for both adults and children. You also kind of defined how you monitor asthma. So there's like introduction of objective tests to even monitor asthma, which wasn't there before other than, you know, questionnaires that we had, and also managing asthma in adults.

So the way we manage asthma in adults is going to change, and I call it a sea change because it's just the whole approach is changing for at least children over 12 and the adults on how we manage asthma will be very different to how we've been managing so far. So other than that, what we want to do is to help people to control asthma better and reduce the risk of asthma attacks.

So the guidance will hope to achieve good diagnosis, which is accurate, monitor and manage symptoms better, and also reduce the risk of any attacks or exacerbations of asthma.

Very, very worthy. So I guess if we start to dive into it then, we take diagnosis as our first point. Do you want to fill us in about what the updates here were for children and young people in terms of diagnosis? Yeah, so I'll start with the history. So I think, you know, we can't get away with having a taking good history and that covers obviously children and adults, you need to have a good clinical history, find out about the symptoms.

Is there any reported wheeze, any noisy breathing, cough? Have they been, you know, breathless, you know, is there any chest tightness, any variation of the symptoms, you know, during the day or night? Has there been any triggers of asthma? Like, you know, we all know about the dust and allergies and all the other things and personal family history of asthma. And of course, history of atopy in children is also important, you know, their eczema or anything like that.

And whatever you do, you just have to record the basis of your diagnosis so any previous attendances with chest infections or symptoms you know all of those things you would take into account um with children that's what you will think about but with adults obviously you'll think about occupational health and things like that and then um that's history anything different with examination and testing so examination again

key thing i mean looking at um for children you'll assess the whole thing you know the the height uh if you can the weight you know and listening to the chest listening to the heart. Looking at the general examination, their eyes, their fingers, you know, look for any signs of any other illnesses that you might find. And of course, if you find a WEEZ, then record the WEEZ. So that's really important to do from an examination point of view.

And then if you have a clinically suggestive history of asthma, then you would think about moving towards objective diagnostic tests that they're recommending.

And this is a bit of a change as well, isn't it, in terms of the actual tests? So I'll try and cover, say, for children between 5 and 16. So what you would do first is do a phenotest. So most of us would know what a phenotest is, but it's actually a blowing test. It's a very simple test, you know, lasts for about 6 to 12 seconds, and it measures the exhaled nitric oxide. So basically, it's fractional exhaled nitric oxide.

And once you do the test, if the test is done accurately, it gives you a number. And if the number is more than 35 parts per billion, and this is children between 5 and 16, then you can confidently say that they've got asthma. Obviously, you'd be doing these tests once you've done the history, the examination, you're thinking that they have got asthma. And you do the phenol test, and if it's more than 35 parts per billion, then that's asthma.

If phenol is normal or is not available, then you would move to spirometry. And this is where the suggestion is that you should do spirometry but also you should give them inhalers to see whether there is any reversibility or not. Regardless of whether the spirometry is obstructive or normal or not, the suggestion is do the spirometry, give them the inhalers for under microchrome salibrethum and then repeat it again to see this reversibility.

And if there's reversibility of more than 12% or more from the baseline, or at least 10% or more from the predicted normal FEV1, then again, you would say that they've got asthma. So just one test needs to be positive. So if pheno is positive, you don't even move to the next level. So if pheno is not possible or negative, then only move to the next level, which is parametric. Again, you know, previous draft didn't have peak flow variability.

But after the draft went through consultations and everything, peak flow variability has been brought in. And that's mainly because if there is lack of spyrometry with bronchodiality reversibility and pheno, you can do peak flow variability. And that's, again, twice daily for a two-week reading. And if there is a variability of more than 20%, and that's basically in the amplitude of the peak flows, then you would again say that they've got asthma.

Again, they're only saying one objective test is needed. If that is also not possible then you move to the next bit and this is where the blood tests come.

Yeah and i think that's the reason is with children blood test is a bit more trickier than adults um so the suggestion is that we should do tests for house to smites um so either you can do a skin preg test which is may not be easily available for all of us yeah or you do a blood test for an ig for house to smite if that's raised then again you can say that they've got asthma. And you can also do a total IG and yeast liver count.

So if yeast liver count is more than 0.5 and the total IG is also raised, then again, you can say that they've got asthma. So that's a decent history and we can't get any of the, for whichever reason, we can't get a pheno, we can't get a spirometry, we can't get a peak flow diary. We could go for the blood test instead.

And if it's house dust mite positive, so you just offer house dust mite, you diagnose has asthma. That's only if the history is consistent with asthma and then you've kind of, because if the history is consistent with asthma and they're really allergic to hazardous mites, then there is confidence in the evidence that we have that it's more likely to be asthma. But, Most of us would do an IgE. When we do bloods, we'll do a IgE house to smite.

We'll do an IgE total. And we'll also do an Easter full count. We'll do full blood count because you're not going to just do an IgE house to smite. So usually you'll have this battery of tests. And then if house to smite is positive, Easter full is more than 0.5 and total IgE is raised, then you can confidently say that this child has got asthma, provided that they've got the symptoms. And if you still can't diagnose, then you refer to pediatrics for any further test.

Yeah it's just not quite fitting things aren't quite right yeah that's right so i think most of these i mean i i actually after these guidance was released only then i saw a child who already had these blood tests done already and then in our practice we had pheno and the pheno was high so this was all before the diagnosis it was all there but we never diagnosed the child with asthma but once the guidance was out and the child was in front of me the pheno was

raised the eastern folds was raised they were allergic to house to smite the total ig was raised so it was like a no-brainer to diagnose that child as asthma and confidently say to the parent which was really amazing for me because otherwise we've got this we've got this but uh we'll try this but now i can confidently say you've got asthma and we need to treat you yeah which is really good for the parents really good for you as a clinician and i think it's it's it's really a step

in the right direction for us no that is really good i think i just the one question i had it just seems really interesting to me that so you said if the phenol's negative you move to spiro if it's negative you can move to peak flow it feels like you're almost hunting for a diagnosis and you're going to like less less good tests in a way um is there anything about that in the in the guidance.

So i can't remember the exact numbers but then it was all about you can diagnose at least a good 30 40 percent of patients with asthma with phenol alone so you're kind of capturing the remaining fewer percentage after that, if that makes sense. So I think the evidence is that you might be able to diagnose at least 60% of the patients.

Don't quote me on these exact figures because there's like a methodology to do that, but they were able to kind of say that if you do these tests, you should be able to diagnose a good percentage of patients and only then be able to refer to peds. So the cost effective way of doing that would be do a phenom first because you would be able to capture the majority of asthma patients with that. And then the next cost effectively be Spider-Man to irreversibility.

Peak flow availability was not there in the draft, but it was put in because the clinicians and other stakeholders felt it's something really important, could be easily done, and it could be used to diagnose as well. So that's one of those, you know, cost effective, but more time efficient and, you know, lots of appointments needed. Parents need to be really careful with how they monitor and how they do that and all of that.

And then of course blood tests again has to smite ig all of these you know will pick it up but again not the easiest thing to do for children and may not be the most cost-effective thing to do when you compare pheno with a blood test that goes to lab and all of that does that does that make sense so it's not like hunting for something yeah no it's about cost-effective versus how many you're capturing so yeah it's like a balance of all

the different factors that makes sense now absolutely that was a way yeah if it was up to us probably we'll do everything but it's just about step one two three and four no i think it does it it makes sense in terms of if it's if it's positive it's useful but if it's negative it's not necessarily it might be a false negative so keep hunting especially if it's clinically it sounds like asthma so yeah um if you know i would love to have access to um what is there any

kind of drive around greater manchester or how's it working is.

There kind of a bit more resources being put into practices being able to do it or um so at the moment i'm hoping to get things commissioned across great amount of steps so for both spyrometry and pheno spyrometry at least at a primary care network level pheno i think every practice should have one um and i think so far practices have not been um keen to have because of how much it actually costs to to use the um disposables that he would use um

yeah the mouthpiece and stuff like that which which itself can cost um not not a lot but usually it varies from about three pounds 50 to about nine pounds 50 depending on which machine you have but then it's still expensive from a practice point of view but it's still much cheaper than actually sending a blood test to the lab and then getting a result back from the from that so i think it's about um practices either uh would be supported to have a pheno um or they'll

be drive for practices to get pheno themselves you know with i don't know how the national contract and other things will change with regards to that um so either it could be a commission procedure separately or it could be something within the national contract you know in all the negotiations because that's something that i think should be a vital part of managing asthma um especially when it's the role for pheno is coming in monitoring asthma and also managing

asthma as well so it's not just for diagnosing. That'd be ace for patients to see that their great management has got like a number.

You know feel really good about their management yeah absolutely i mean it positively reinforces them or it kind of makes them feel guilty so so we do have pheno and then they come in and then it's high and then said did you use your steroid inhaler and they're like and then you kind of encourage them and the next time they come and then it motivates them it's just like the carbon monoxide test for stopping smoking and then you kind of had that you know

if you see that negative and you're like yes i've done it so similar to that with asthma control as well yeah.

And hba1c yes yes it is um so for children under five any any recommendations there because that's notoriously tricky because i remember doing the feasibility study with nice when the first nice guidelines came to see how feasible it is to get children to do sparametry and pheno i think all of them struggled i think the only child managed was eight and over um so nice is suggesting you should try objective tests once they turn five and keep trying and and i think pheno test children

were able to manage better than the adults but if they're less than five and you've got a good clinical history of asthma they've been coming again and again treat them with inhaled cortic steroids in line with the recommendations of medicines and that we have you know especially they should have salivitis and an ICS and then do the objective test like you say when they turn five or more yeah and then you can just monitor their response to the actual treatment

as a way of trying to work out if it is absolutely so you kind of do that for eight to twelve weeks trial and then kind of review them again sticking with thinking of children and younger people and diagnosis I was thinking through some of the sort of tricky bits we get in in clinic and so imagine we've got eight-year-old James he's come to see us and it's his third, lower respiratory tract infection this winter it's been a bad winter for him.

But when we're taking the history actually when he's well he does get some wheezing he gets nocturnal cough when he's well when he's not got a chest infection and when he's exercising he gets wheezy and coughs as well so actually it's quite a lot in the history there that's making us think this could well be well be asthma and we don't at the moment have pheno in our practice and it would be great we think he'd manage spirometry quite well he's

quite a good kid but he's currently in the middle of a chest infection and we're quite keen to treat him because he's got quite a lot of symptoms but if he was on an inhaled corticosteroid that might affect his spirometry and any advice about that kind of classical scenario? Yeah, the suggestion is if they're acutely ill, you go ahead and treat them. So don't be worried about having an objective diagnostic test.

But if you have pheno in practice and they're there in front of you, I just go and get the pheno, do the test, show that it's high. And that's, if it's high, then again, clinical history, if you know it's high, you'd be thinking that this is asthma. So that's probably, I'll look at the future, that we'll all have a pheno and we'll be able to have access. Like a point of care testing, you know, only take 6 to 12 seconds, go there, get in.

You know, like we do, you don't do. Just get a pheno done. And that's the best way possible. And then treat the chest infection that you need to. So you can use it during an acute examination? So the suggestion is that you can do objective tests when they're acutely ill. That's ace. But then if you don't have access to objective diagnostic tests like pheno or spirometry or whatever, then the suggestion is to treat the acute episode.

So treat them with oral corticosteroids if you can, or if it's needed. And of course, inhalers and other things that you would need. But we've got to bear it in mind that inhaled corticosteroids obviously will affect your spirometry reading, will affect your pheno readings. So there is a risk that we may have negative objective diagnostic test in people who are treated.

So, if people's acute symptoms are better and you don't need to start them on inhaled corticosteroids, for example, then you can say, come for an objective diagnostic test in the hope that we'll be able to capture asthma by doing phenol as parametri. But while waiting, if they get exacerbation, then again, they should really come back.

So, clinically, I think we're confident that there's asthma, but it's always good to prove with an objective diagnostic test just in case it's something else completely different so in our practice we do six weeks after a chest infection before we do spirometry with reversibility um how long after stopping steroids do you do you know so six weeks is usually six weeks yeah good sign when um so normally the suggestion is now you need to review people when you start

them on eight to 12 weeks of ics but six weeks stopping them will be good enough period to kind of assess them again for spinal material reversibility and pheno as well but if you can get it done before any of these then that's the best yeah i'm excited to get pheno now.

I've already had practices emailing me that they've got a pheno machine now since the new nice diagnosis on nine nice diagnosis protocols it'll be good it'll be good i think for practices it'll be really good so that's um that's our under fives our five to sixteen so what has change in the guidance for adults then in terms of diagnosis?

So again clinical history is important, everything that I just talked about early with regards to wheeze, the cough, the breathlessness and then of course the occupational health is really important in adults with, asthma-like symptoms. And the suggestion in this one moves from phenophils. Of course, phenol and their suggestion is to do blood eucenophils as well. So FBC, phenol, look at the eucenophils. If it's above the normal lab reference range, phenol is above 50 parts per billion.

You could say that they've got asthma. If that is negative, then again, it's the same logic that you'd use, that you go on to do sparametry with reversibility. Again, you would do spirometry and reversibility, regardless of whether they've got obstruction or not. If the chain in FVU is more than 12% or more, as well as the volume difference should be about 200 mils or more in adults, then again, you can say that they've got asthma.

If that's negative, of course, or you don't have access to any of these, then you do peak availability. It's the same with adults as well, which is 20% or more.

If all of these tests are negative and you're still thinking that they've got asthma because like I said a few percentage of patients will still not be diagnosed with any of the tests that I just described above and they are the ones which should be referred to bronchial, challenge test and that is something that you would refer to secondary care.

So it's important to go through all of that again most of the patients with asthma in primary care we should be able to diagnose using the abort test if you're not sure then refer for bronchial challenge. Bronchial challenge. And yeah, great to mention the occupational history. So if they've got occupational asthma, is that right? Yeah. It's about, you know, if they go on holidays, they feel better. But who doesn't feel better on holiday?

But as soon as they come back to work, the asthma symptoms flare up and usually be work. You know, there are lots of occupational things which can trigger asthma. Yeah, that's really good. So I guess using the same structure, then if we start with the children and young people, what has changed in terms of their management?

So I think the key things that I would want to highlight is first is, and this is for all age, not just for children, is that do not prescribe short-acting beta agonists. So don't prescribe salbutamol on its own to people of any age with asthma without giving them a concomitant prescription of an ICS. So please don't give salbutamol to any child, even if you suspect, give them salbutamol plus an ICS. And that's for any age.

We'll obviously go on to talk why you shouldn't be giving salbutamol at all for children more than 12 and adults, because then we'll talk about the newer therapy. But this is something that I want you to remember. Don't give it without the concomitant prescription of ICS. And the other thing is, if you start or adjust medicines for asthma, review the treatment in 8 to 12 weeks.

And that's something that we should always do. So again, it's not about giving them and then asking them to come back in four weeks. I think eight to 12 weeks is a good period of time so that they can actually see a good improvement in the response to the inhalers and symptoms actually improve. Control is better. No nighttime awakening and all of that. And when they do come back, you can always check their pheno.

If you have pheno, if pheno is elevated, that's suggesting that they're not taking the inhalers properly. And that's something that will encourage you to use those inhalers properly.

If they're using their inhalers really well, and then if pheno is still elevated, then you'd be thinking about that they need further treatment and they are the ones you'd be thinking about referring on to secondary care or increasing the doses of the inhaled treatment you're giving or thinking about they need biologics treatment for their asthma because they're pretty kind of would-be steroid responsive, but they're not.

That means they need biologics to actually help them. Okay. Well, that's really good. So again, with children, it depends what age they are when you manage them. So if children more than 12, and this is children more than 12, so obviously it covers adults as well. So you start them on a low-dose ICS, a low-dose inhaled corticosteroid, and for metrol combination. And there are only a few licensed treatment for that.

So one of them is, for example, is Symbicot. So at a dose of 206, the suggestion is that you take one puff as required. So that's why this is called AIR, which is anti-inflammatory reliever therapy. Does that make sense? So it's anti-inflammatory is in there, which is the steroid component.

And then the formitrol is in there, which is a lab, a long-acting beat agonist, but it's pretty much like a short-acting beat agonist, like the salbutymo, in the sense that the time it takes for the lungs to expand is pretty much the same as salbutymo, but it acts...

For a longer period of time so people feel that they can actually breathe longer and better with that so that's anti-inflammatory liver therapy so the suggestion is use using one puff as required and you can go up to six puff um during the day maximum up to 12 but the suggestion is up to six, and that is air so so if in asthma if anybody says air so that's what it means so that's a-i-r where's the t that's for mart the t from art.

Yeah it doesn't sound as well yeah it doesn't quite yeah i have the same ring we'll just do it so it's hunting for me to really wear and then you can add the words be quiet um and then if if they're still symptomatic on air or they are being waking up at night time or anything like that or having severe exacerbations, then you go on to the low-dose MART. This has got a T and you'll be pleased to know, Sarah. Nice, thank you.

So MART is maintenance and reliever therapy, which is exactly what we've been used to for a while now. So basically, you're giving the same inhaler for them to take it when they have symptoms to relieve the symptoms. And they're also taking this as a maintenance inhaler in the morning and nighttime, and they take it in between. Does that make sense? So again, it's the same Symbicot 206, for example. You'll be taking one puff in the morning and one puff at night.

And then if you have any symptoms in between, you take it whenever you need it. Again, up to 12 puffs is usually what we would say for maintenance and reliever therapy. I think there's a Fobomix in there or something. It doesn't quite roll off the tongue. It took me a long time to learn Fobomix.

But that's another another one that's i think that got the same steroid and uh yeah so so there are some some some medicine which are licensed for mart so that includes a do a rest spiromax um again maximum number of puffs is about 12 you've got fobimix like you say it's an easy healer um which again you can give us a maintenance reliever therapy which again up to 12 puffs um you've got lufo beck which many of you would be now using um so lufo beck or bebeck for um

so they are an mdi so that's something not green but if obviously for children um there isn't anything that's licensed mart so this is i'm talking about you know children more than 12 and and adults really uh because there isn't any proper license once for less than 12 even for mart so anything I think for Mart would be an off-license indication for children. Simbicot, I talked about, so either 106 or a 206.

If it's a 206, obviously, like I said, you use one puff twice a day, and then you use up to 12 puffs a day. Another one, which is licensed, Walk Hair, which is 160 by 4.5. But you don't have to remember all of this because all of this is put together in a guideline from Greater Manchester, which is the Greater Manchester Medicines Management Group Asthma Guidelines. So I chair the group along with Andrew Martin, who couldn't be here.

So which is a good guideline and it talks through all of these inhalers and how to step up. And it's consistent with NICE as well. It's so good. It's got pictures of the inhalers so you can use it with patients. And then it's got pictures of cars.

And then green cars because there's not many it's you know the carbon footprint's lower and then yeah the red cars because the carbon footprint's high so yeah really nice yeah absolutely yeah well done well done all of this is done with it with you to kind of get more green and of course while you're going green you're also managing the children and the adults with the asma better we're still working on the children's guide so the guide that we have is mainly for adults,

but it'll be pretty similar for the for the children more than 12 years old because their management is pretty similar but i'm hoping that we'll have the children's guide in ggg soon is it worth touching on the um the children's guide now in terms of how things might change or is that is the general principle of air and mart the same for kids so general principle air and mart is the same for kids but what's different is like i said if they are between five and

eleven um then the suggestion would be to use twice daily dose ICS with the Saba bearing in mind what I said in the beginning that never gives Saba on its own so it should be Saba with an ICS okay so twice daily ICS with a with a with a with Saba so like something like your Clenil um or um QVAR or something and then you would move to moderate dose ICS with a Saba as well um and then pediatric low-dose mart you can try, bearing in mind that it's not licensed.

But we would try and get the, children's guide out soon but it may take a while before we do that no that's fair enough that's useful to cover though definitely so below five it'll be the same um sort of treatment which is the the low-dose ics um plus salbutamol because there are not many licensed for the below fives in four years you know you can use some other inhalers but again you know i don't want to confuse listeners now but once

we have the children's guide then we would obviously um possibly come back again for a podcast sounds good for children's asthma yeah i'm just thinking you've covered the maximum doses that's really useful so um the you know how you said it's six puffs um as or even maximum is 12 puffs for air where if you're doing that kind of anti-inflammatory reliever therapy and is that the same um for mart as well where it's like 12 puffs so

mart is up to 12 so with air the suggestion is because it's a reliever anti-inflammatory reliever therapy that means you're assuming that their asthma is well controlled okay because if it's well controlled you would move them down from mart to air okay so that's where the suggestion is yeah suggestion is take up to six so that your dose of steroids is much less.

If they have to move from six to eight or 12 that means they really should be on a mart because otherwise you can imagine their life they're they're always reaching up to their reliever therapy, which you don't want them to. I mean, you want them to, but if you can control that without, and if they increase the dose of steroids in the morning and the night, then they're better. Rather than taking up to 12 puffs. Yeah. I'm glad I asked. So their suggestion would be to step them down as well.

Once you think your patients are very well controlled on Mart, try and step them down to low-dose Mart and then step them down to air as well. In summer, people might be on air. And then when you hit September. Yeah, it depends. Yeah, it absolutely depends. Depending on hay fever. Yeah. You know, if they've got more hazardous mites and all of that analogy,

then their asthma control might be much worse. There's thunderstorms are really bad for asthmatics because it just brings all the bone down and everything and that can trigger asthma attacks. It depends who your patient is. Right. That's actually a really, yeah. So that was a throwaway comment, but really, really good response. Yeah. But winter again, virus is known. But it depends on what your trigger is. You go on a holiday to a farm where there are more dogs and cats and house dismights,

then you'd have more problems in summer. Yeah. No, that's great. Thank you. um and that yeah just that holistic approach isn't it really so managing everyone differently.

Um so steroid cards i just thought i'd ask you about them and are there certain criteria when would we be thinking about giving a patient a steroid card for their high dose steroid inhalers so again it's based on age so all children under five if you're giving them inhaled corticosteroids then they should get a steroid warning card. That's just normal practice because less than five, they're really sensitive.

And whether we like it or not, inhaled corticosteroids can stun the growth and there are side effects, so you should give them a steroid warning card. Because especially if they're present in crisis, you need to know that they've been on steroids, even though if it's inhaled corticosteroids. If children are aged five years in a bowel, then it depends on which steroid it is.

So if they're less than five, like I said, it's all doses. If they're between six to 11, then it depends on which steroid it is. So the ones in Simbicot, for example, the budesonide, the doses is over 400 micrograms. You'd be careful about that, about which steroid you're going to use. If you're using beclomethazone, like Clenil, for example, and then again, if it's 400 micrograms or more, then you would think about giving them a steroid warning card.

If it's fluticasone, that's only after 100 micrograms. Then you need to be careful about which steroid is being used. Again, if it's a Xeratide, then you would be thinking that I need to give a steroid warning card because fluticasone is more responsive even in low doses.

If they're more than 12, then it's up to 800 micrograms for the buddhistonide. For beclomethason, it's up to 1,000.

Ofolitics on just 250 micrograms is enough and serotide is a is a good example like you said, beclomethazone clenil is a good example beiracinide pulmicotricin because it's a good example i like it it's a bit more complicated it is isn't it so over 12 um it's just making me think yeah i'd definitely need to just look up because yeah it's it's being very aware that you're yes have a sticker somewhere yeah yeah that you're be aware that the steroid doses are very different because the strengths

are very different absolutely so when in we're almost there with the children's guide so we've got this table in the children's guide in draft but i'm hoping that once it's there then you might print it out. I mean any surgery with all the gtplmg guidelines printed that would be good news for me, that's the hope so so i mean the same information i said we're putting it in a tabular form and hopefully that will be there in the children's guide as well because they're the ones who really need it.

Because adults, by the time you reach up to 1000 micrograms, It's quite a lot of steroids. But for children, 400 is easily reachable, isn't it? So that's why it's more important, the children's guide than the adults guide as such.

And you have talked a little bit about green prescribing as we've gone along, but it just might be worth asking you here if there's anything else to highlight or any other advice that you have about how to be a bit more green. Simple advice for adults would be follow the GMMG guidelines. I think Sarah's already mentioned the beautiful green cars and the red cars and why they're green and why they're red. So at the moment, the inhalers that we have, dry powder inhalers are green.

So those are the inhalers where we actually use the patient's inspiratory ability to take the inhalers, to break the components down and to take those inhalers. While MDIs are the ones where you press and then they use obviously a not so carbon friendly things to actually get the inhaler out of the device rather than using our own inspiratory pressure to actually get the inhaler out. So that's where dry powder inhalers are the most carbon-friendly and they are the green options.

So in GTPMG guidelines, we've described each inhaler and we've created green and red. So red are the ones not to give unless the patient actually needs it. So green is the one that we should be suggesting that you do.

Like, for example, like we talked about the different inhalers, for example, symbi could be one of those green inhalers so is duress and um walker like i talked about so they then move up as well so you can have just one inhaler which you can move up right up to the end and then add more treatment if you need to as well um and then in terms of management for adults anything else that we need to go over hey i think the only thing would be to think about um when

would you start them on Monty Lucas? Because we're used to starting them on Monty Lucas, aren't we? So the suggestion is, if you've given them low-dose mart and you've gone them to medium dose mart, if the symptoms are still not controlled, bring them for a pheno. And if the pheno is still high and they're using it really well, then the suggestion is that you should actually refer them to hospital for biologics.

But if the pheno is not high, but they still have symptoms, those are the patients you can actually try them on monthly cast. And then again, review them in 6 to 12 weeks or 8 to 12 weeks and then stop if there's no response. And then refer if there's a response. And of course, you've been successful. So it depends on how.

What's the underlying reason behind the asthma which again secondary care would understand that better that sounds interesting it is it is interesting um did you um so for monte lucas do we ever use it in children still you it's still in the guidelines right still in the guidelines um it's a funny one though isn't it in terms of some of the potential side effects of it yeah i mean nightmares and other things are there but again um monte lucas is

a good drug if you know there are lots of allergies um then children do respond well but the the the main messaging would be to get the steroids optimized um along with laba if you can and i think that's the best advice for children moving up to montelukas and other things if you think that they would help but again it's a trial no improvement then you stop but side effects are not that palatable for adults is there a um mrha warning is it mhra mhra warning about

mental health and montelukast yeah there's a few issues around that absolutely which is why you know the guidance to suggest you know only if um pheno is controlled and they don't moderate those ics laba and they manage well then try montelukast if it's not controlled then you think about biologics rather than doing montelukast yeah that's really good you can use llama and other drugs as well.

Um if you don't want montelukast then llama would be the the other drugs which is teotropium which you can be using again due to pulmonary guidelines goes into depth but when you do that and how you do that as well i was just going to say before we get to our kind of final questions are there any other points that you want to highlight about the the guideline about any changes anything else that's important um so i think the key thing you know if your patient is on salbutamol

alone, please review your registers. You know, there are lots of patients who are on six or more salbutamol in a year. And that's something which is not right, because that's suggesting that either the asthma control is poor or they're just not managing it well. They need to be brought in, review them to see whether you can put them on IR or MOT, especially for anybody more than 12. So you can definitely do that.

For children, it's a bit more complicated, you know, again, you can try and get them on the ICS plus Saba rather than Saba alone, and then see if you can optimize their treatment better. So really for adults, nobody should be on salbutamol, they should really be on.

Air or mart i think that's the key message um unless you know there are always exceptions isn't it we were talking about side effects and palpitations and all the other things but um so this is like unless there's a good enough reason for you then you should try under other than that you know they should really be on air or mart um and then the other thing would be um there are people having extubations but not on the right treatment again so review anybody who's had you know two chest

infections or asthma exturbations in the last year or more and then they're not on the right treatment you need to think about treating them as well with ICS and. Another key message which I've forgotten to say is inhaler technique so NICE goes into length on whenever you do you know whenever you see a patient you review the inhaler technique when you change the treatment you review the inhaler technique when they come with an exturbation need to be with the inhaler technique.

So they kind of keep underlying the inhaler technique a lot. And then the other thing I didn't talk about was obviously tobacco addiction treatment. So smoking is a big trigger for our asthmatic patients, as well as parent smoking is a big trigger. For children, vaping, unfortunately, is something which now we know that it's much more dangerous than we thought. And of course, parents smoking or carer smoking is also a risk for them.

And that's something that we need to be aware of and advising our children, parents and carers as sensitive as we can. And there's obviously new tobacco-dependent treatments. Again, there's GWNG guidelines on that, which you can have a look at. And vaccinations is another thing, which I didn't say about. But again, in your asthmatics needing these, they're high risk, so they need the clue vaccinations for those who are older and they'll be eligible for pneumonia vaccinations.

As well. And then check the adherence, you know, making sure that they are using it properly, ensure the diagnosis is correct. Now it's much more easier to do that if you have those tests available. And then check for exhalations and oral steroid use, because I think if they're using too much steroids, prednisone for every exhalation, then there's something wrong. Then they should really be picked up and referred for secondary care to give them biologics.

So again, that's something that you need to be mindful of. So in terms of resources, you mentioned GMMG, which is a brilliant plug from all of us, I think. Any other resources that you use with patients or that you want to highlight for clinicians? So we're trying to kind of come up with, I mean, of course, this podcast would be good resource. Like with any example, go back and say that what I've said is accurate or not.

Uh but but of course nice guidelines are much more easy to read so have a look at the nice guidelines as well and and obviously you there'd be nice cks on this as well which has been um, updated as well on uk is the charity which again goes through the patient um resources and they talk about air and mart which is helpful um so those are again the resources that we can use. I use their videos to show good effective use of different inhaler types.

And there's a website called Right Breathe, which again talks about different inhalers. But usually most of the inhalers that I did ask my lung UK website and you can actually go through them, go through them and then speak to your patients with the videos open. Perfect. So yeah, that's brilliant. That's a really good walkthrough. Any other points that you wanted to mention before we wrap up?

Take your time with your asthmatics now and get used to air and mat, especially at least in children more than 12 and adults less than 12. I get it that it's a bit more trickier with the reduced amount of inhalers and the off-license and everything. But with adults and more than 12, you should be confident to move them to AIR and MART. And I think that's what I would encourage GPs to kind of look into what is AIR, what is MART. And it's a sea change.

But if we have children more than 12 and adults on AIR and MART, that would suggest that their control is going to get much better, rather than using six salveutimols in a year without any ICS and then still ending up in hospital and any attendances.

And our asthma diagnosis isn't great because one in four of our A&E attendances with asthma are not on the diagnosed GP register, so again it's something that we need to be thinking about with the new guidance how can we then make it better so rather than coding them a suspected asthma you would have these tests already done like your FPCs and other things use them, and hopefully we can sort out a commissioned GM model but if not practices can

afford to buy them and and do them then by by all means get a pheno device it'll be really helpful. Patients will will really benefit by the sounds of it yeah.

They will I mean it's all done for patients isn't it um they will and and it's going to be green as well because we'd be using less inhalers you know salbiotamol especially ventolin is really not carbon friendly, and if you use too much of that and they're still not getting better it's not good for the patient not good for the environment, not good for the NHS as a whole. So if you can do something on that, then we'll make a big difference. Amazing. Yeah, perfect.

Thank you so much. That was a really clear and coherent overview of the changes.

So really appreciate it. Thank you very much. All right, Sarah. So that was an absolutely wonderful chat with Raja. I think he did so well with us throwing all of those questions at him, particularly with such a huge change in guidance and it being such a common presentation.

So yeah, I think he did fab. What are the big takeaways that you have Sarah yeah I loved um up top that he did start with the history because um I think when I was thinking about what questions I wanted to ask him I was kind of quite hurriedly thinking of yeah what's new what's changed and I think it is it's just that don't forget this is the typical history these are the symptoms that we're looking for so you know especially because there's so much that you can do in terms of diagnosis and but

yeah I'm really I really really wish we had a pheno machine because it just sounds so useful like in the moment that you can actually use. It um as point of care testing um but yeah just that whole thing that whatever you. Do after that just just reminding ourselves.

Like don't forget it's all about the actual history as well yeah especially with things like they're quite quite interesting the eosinophils and the IGE and the house despite side of things it's really interesting the way that they've um come on with different types of investigations to diagnose it um but yeah exactly yeah I agree I'd written just the importance like you said of the fact that all of this is relying on history if the history is not typical of asthma

then none of these other bits of the guideline really matter and it is that's like number one you have to have that clinical suspicion for all of this other stuff to make sense really yeah and also just the fact that I don't know why it's taken so long for the three guidelines to merge and actually become easy because asthma is just so common and so big it's like why is it taking all this time um for these to actually line up for one so yeah i thought it was really good that

they finally are yeah it's really interesting it would have been kind of nice to be a fly on the wall when everyone's discussing all these things and the pros and cons and the specificity sensitivity of all the tests and things but um yeah no i thought it was really interesting and i think the other thing is as well is that that um management side of things where it's like don't forget to go back and see is this working you know

concordance thinking about is this really the diagnosis and if it is um you know is it good enough in terms of the management and getting those respiratory referrals in relatively early i love the whole and not over relying on on salbutamol or sabba.

Um just because yeah huge huge importance in terms of like preventing deaths from asthma so that was that was great to go through and I am thinking of even though I'm aware of it and I try my hardest how often if you're just sort of trying an inhaler that you just go for especially in children you just go for the blue and then think to review but the difficulty of then those reviews coming up and actually spending that bit of time going no here you go here's the two inhalers Yeah, absolutely.

Yeah, I think the, like you said, I think the biggest takeaway in terms of management for me was that like don't just prescribe and leave, like prescribe and monitor, prescribe and check. Definitely make sure that you've absolutely maximized therapy to get them under control because of just how important it is to have controlled asthma when you've made these diagnoses and just for that kind of mobility, mortality side of things.

So yeah just and I think hopefully this guideline has actually made it a bit easier to be able to step up therapy and to kind of have a bit more of a consistent kind of stepwise plan and hopefully it definitely sounds like it when he's repeating it to us anyway yeah and so hopefully that's going to help now going forward I love the air and mart I thought they were really good and that you know so if it's milder symptoms the air is pretty good and and then step step up to mart if not and then

you know vice versa really well controlled you can go back to air and the astma uk has got really good explainers so i'm going to be um i think that's my homework to myself is like go and look at their explainers and pinch pinch some of the spiel i liked the whole optimize the steroid treatments before considering other options in terms of the medications um but yeah thinking about adherence technique i really like getting into the nitty-gritty of like are you

actually using that inhaler you know is it working yeah some of the inhaler techniques that can be quite.

Interesting yes and i also think that the um the introduction of pheno is going to really help there um like we talked about in the episode i think just having that ability to actually monitor yeah not i know you could maybe have monitored with spiro but it just feels like this is a much easier way to be able to monitor treatment and not not kind of just check in on the patient and make sure that they're doing what you say but i think it's just that joint ability to

be able to say well look this is your number now um like you know what are you doing how you get on with treatment is it working for you i think it just makes that conversation a little bit easier and a bit more transparent yeah i think it will be good if more people can get it into practice lovely um so thanks so much for listening we hope you all enjoyed it we we certainly did And thanks so much to people who are filling in the survey or leaving us

feedback or sharing the knowledge of the podcast, because all of that really helps us carry on. So thank you and please carry on till next time. On Primary Care Knowledge Boost. Music. This podcast has been able to continue to date due to the support of GP Excellence, Wigan Borough CCG, Greater Manchester Training Hub and the GP Fellowship Programme, as well as Greater Manchester Health and Social Care Partnership.

Just a friendly reminder that these podcasts are for healthcare professional education and shouldn't be used for medical advice by the general public. This episode was recorded in Greater Manchester in 2025. Guidelines can vary by location as well as over time so always check for up-to-date local and national guidelines before making treatment decisions. The content is based on our interviewees opinion and interpretation of current best practice.

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