Asthma: diagnosis, monitoring and chronic asthma management

Why the committee changed the recommendations

The evidence for children and young people found that increasing the dose of inhaled corticosteroid (ICS) when asthma control deteriorates did not result in any benefits or harms compared to the usual dose in terms of reducing subsequent asthma exacerbations. It was limited to only 1 study with a small number of participants who had a personalised action plan. The committee also looked at studies in adults, but agreed that the evidence was not applicable because of the high average age of participants.

The 2017 guideline recommended that quadrupling the dose of ICS could be considered within a self-management programme for children and young people whose asthma is deteriorating. The 2020 update committee agreed that this 2017 recommendation was based on limited evidence, mostly in adults, and that the new evidence identified in this update did not support this. However, it also agreed that there wasn't any significant evidence to suggest that increasing the dose of ICS is harmful compared to the usual dose. Based on their experience, the committee agreed that increasing the dose of ICS within the licensed limit would not adversely affect child growth. This was supported by the evidence, which showed that increasing the ICS dose in the short term did not result in a statistically significant decrease in child growth, even though the doses used in the study exceeded the licensed limit. Therefore, the committee decided to remove the 2017 recommendation rather than replacing it with a recommendation that prohibits increasing the dose of ICS.

The committee discussed the importance of a personalised action plan to guide children and young people if their asthma worsens and to reassure them that they are in control of their treatment. Children and young people who find that increasing their dose of ICS is helpful when their asthma control worsens should be able to continue to do this as an agreed strategy in their action plan. However, based on their experience the committee members agreed that it is important to review the child or young person's self-management plan if their asthma control is deteriorating. Reviews involve checking current medicines and inhaler technique, discussing any factors that may be triggering symptoms, discussing adherence and education needs, and reviewing their action plan. They should be carried out as needed, in addition to annual review. The committee also stressed the importance of continuing regular ICS maintenance therapy, or restarting it if the child or young person has stopped taking it, to prevent deterioration.

The committee discussed the importance of an individualised approach for children and young people, because they have varied and changing support needs at different ages. Studies have shown that most child asthma deaths involve children who have frequent but mild symptoms that are not responding to management in their personalised action plan. This recommendation should help to ensure that these children and young people receive the support that they need if they start to have problems with their asthma control.

The committee agreed that further research is needed to give clearer guidance on increasing the dose of ICS in children and young people within a self-management programme and made a recommendation for research on increasing the dose of ICS within a personalised self-management programme for children and young people to promote further research and inform future practice.

How the recommendations might affect practice

The recommendations will lead to an increase in the review of self-management programmes for children and young people and reduce the variation in current practice for this. The increase in resources needed for this is likely to be offset by a reduction in the cost of treating asthma exacerbations.

Return to recommendations