The 2024 NICE asthma guideline update marks a transformative step in asthma care, especially within primary care settings. With an emphasis on objective diagnosis, safer prescribing, and sustainability, this new guidance aims to improve outcomes and reduce variation in practice.
In this article, we explore the key updates that healthcare professionals should know, and how to implement them effectively in primary care.
1. Objective Testing is Central to Diagnosis
The updated guideline reinforces the need for structured, objective assessment:
- Fractional exhaled nitric oxide (FeNO) is recommended as a first-line test for detecting airway inflammation (NICE NG80).
- Spirometry with bronchodilator reversibility confirms airflow obstruction and response.
- Peak flow variability is a supportive tool when spirometry is unavailable.
- For children under five, diagnosis should be based on clinical judgement, with reassessment after the age of five.
Objective testing reduces overdiagnosis and ensures appropriate treatment is initiated.
2. Moving Beyond SABA Monotherapy
A landmark change is the shift away from using short-acting beta-agonist (SABA) inhalers alone:
- Patients with mild asthma should now receive low-dose ICS-formoterol as a reliever therapy.
- This approach aligns with GINA’s global strategy and is supported by evidence linking SABA overuse with asthma-related hospitalisations and deaths (GINA 2024 Report).
- Using ICS-formoterol provides both immediate relief and anti-inflammatory protection.
This move aims to reduce reliance on SABA and prevent treatment-related harm.
3. Revised Stepwise Management Approach
The new stepped-care model focuses on prevention and early control:
- Initiate all patients with low-dose inhaled corticosteroids (ICS), even at mild stages.
- Where suitable, offer Maintenance and Reliever Therapy (MART) using ICS-formoterol, simplifying treatment and improving adherence.
- Treatment escalation should aim to prevent exacerbations, rather than simply controlling symptoms.
You can explore the updated stepwise treatment tables in detail via NICE’s visual summary.
4. Personalised Asthma Action Plans and Follow-Up
The guideline stresses the importance of structured reviews and self-management:
- Offer a written personalised asthma action plan (Asthma + Lung UK template).
- Review patients at least annually, or more frequently if they are high-risk.
- Assess inhaler technique, adherence, environmental triggers, and smoking status.
Empowering patients to understand their condition and manage flare-ups is key to improving outcomes.
5. Prescribing for Environmental Sustainability
The NHS has committed to net zero emissions by 2040, and prescribing practices must reflect this goal:
- Prefer dry powder inhalers (DPIs) over pressurised metered-dose inhalers (pMDIs) where clinically suitable.
- Switching inhaler types can reduce carbon footprint significantly (NHS Greener Inhaler Guidance).
- Patients should be counselled and trained during any transition.
This aligns with the NHS Long Term Plan’s commitment to reduce emissions while improving respiratory health.
6. When to Refer to a Specialist
Referral is essential when:
- Asthma remains uncontrolled despite stepwise escalation.
- Objective tests are inconclusive or diagnosis is unclear.
- There is suspected occupational asthma or frequent exacerbations.
- Specialist input may be required for biologics or comorbidities like severe allergic rhinitis.
Refer to your local Integrated Care Board (ICB) for referral pathways and asthma clinics.
Conclusion
The 2024 NICE guideline update offers an evidence-based, patient-centred, and sustainable approach to asthma care. For primary care clinicians, it presents an opportunity to revise outdated prescribing patterns, promote objective assessment, and support patients more holistically.
To stay current with best practice, review the full NICE NG80 guideline and incorporate these updates into asthma templates, reviews, and prescribing protocols.