Revised British Asthma Guideline from SIGN and BTS
Self-monitoring in type 2 diabetes
Add-on therapy with montelukast may be safer than salmeterol in the long-term
What’s new from the National Prescribing Centre?
It is still important to review people with asthma regularly and step down treatment.
In the new British Asthma Guideline,1 the familiar stepwise approach to asthma management is unchanged from previous versions. Also, the updated guidance still stresses the importance of reviewing patients regularly and stepping down treatment as appropriate. Before adding or changing treatment, practitioners should check compliance with existing therapy, check the patient's inhaler technique and eliminate trigger factors. In addition, the new guideline contains:
- a completely rewritten section on diagnosis for both adults and children
- a section on special situations, which includes occupational asthma, asthma in pregnancy and the new topic of difficult asthma
- updated sections on pharmacological and non-pharmacological management
- a section on patient education and compliance, and
- a section on organisation of care and audit.
The guideline was produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) in May 2008. BTS and SIGN stress that the guideline does not recommend any specific products.2
For further details see the related MeReC Stop Press Blog (www.npci.org.uk/blog/?p=114)
- Scottish Intercollegiate Guidelines Network and British Thoracic Society. British guideline on the management of asthma: a national clinical guideline. May 2008. Accessed from www.sign.ac.uk/pdf/sign101.pdf on 18/06/08
- British Thoracic Society/Scottish Intercollegiate Guidelines Network asthma guideline: joint statement on pharmaceutical industry advertisements. May 2008. Accessed from www.sign.ac.uk/guidelines /published/support/guideline101/advertising.html on 16/06/08
Self-monitoring in type 2 diabetes
Routine self-monitoring of blood glucose is unlikely to be beneficial in patients with type 2 diabetes who are not treated with insulin.
The view that routine self-monitoring of blood glucose (SMBG) is unlikely to be beneficial in patients with type 2 diabetes who are not treated with insulin has been reinforced by two recent studies. SMBG may even worsen quality of life and waste NHS resources.1,2 Patients, health professionals and commissioners of health care should look carefully at the use of SMBG in patients with type 2 diabetes. In non-insulin treated patients it should be reserved for specific circumstances. Recently updated NICE guidance on type 2 diabetes recommends that SMBG should be offered to people newly diagnosed with type 2 diabetes as an integral part of self-management education, when the purpose is clear and the patient understands how results should be interpreted and acted upon. Panel 1 lists patients for whom SMBG should be available.3
Study details - The ESMON study (n=184) found that people with newly diagnosed type 2 diabetes are unlikely to gain additional benefits from monitoring their blood glucose themselves. Adding SMBG to a comprehensive, structured education programme did not affect glycaemic control (HbA1C) compared with the education programme alone. Also, no differences were found between groups in the incidence of reported hypoglycaemia, use of oral hypoglycaemic drugs or change in body mass index.1 The DiGEM economic analysis (n=453) showed that, in patients with non-insulin treated type 2 diabetes, intensive SMBG approximately doubles the net costs of monitoring with no improvement in glycaemic control, and with a decrease in quality of life.2
| Panel 1: Criteria for self monitoring of blood glucose in type 2 diabetes (taken from NICE recommendations).3 |
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Self-monitoring of plasma glucose should be available:
to those on insulin treatment
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to those on oral glucose-lowering medications to provide information on hypoglycaemia
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to assess changes in glucose control resulting from medications and lifestyle changes
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to monitor changes during intercurrent illness
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to ensure safety during activities, including driving.
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| The continued need for SMBG should be assessed at least annually. |
For further details see the related MeReC Rapid Review Blog (www.npci.org.uk/blog/?p=102) and Podcast (http://www.npci.org.uk/blog/?p=134).
- O'Kane MJ, Bunting B, Copeland M, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ 2008;336:1174-7.
- Simon J, Gray A, Clarke P, et al. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ 2008;336:1177-80.
- National Institute for Health and Clinical Excellence. Type 2 diabetes: the management of type 2 diabetes (update). Clinical Guideline No. 66. May 2008. Accessed from www.nice.org.uk on 18/06/08
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Add-on therapy with montelukast may be safer than salmeterol in the long-term
A systematic review1 has shown limited evidence that oral montelukast may potentially be safer than inhaled salmeterol (NB salmeterol xinafoate is also a black triangle ▼ drug). However, adding an inhaled long-acting ß2-agonist is still the first-choice option at step 3 for people with asthma.
Healthcare professionals who are involved in the management of asthma patients should familiarise themselves with the updated British asthma guideline.2 They should also be aware of the safety concerns over long-acting ß2-agonists (LABAs) and follow recommendations from the Commission on Human Medicines (CHM) (Panel 2)3 when prescribing them for chronic asthma. Despite the data from the systematic review outlined below,1
Study details — A systematic review (13 randomised controlled trials) found that, in patients with asthma poorly controlled with inhaled corticosteroids (ICS), the long-term safety profile of montelukast was better than that of salmeterol. A meta-analysis of the two 48-week trials included (n=2,963) found that there were significantly more serious adverse events (not defined) in the salmeterol/ICS group than in the montelukast/ICS group (relative risk [RR] 0.68, 95% CI 0.49 to 0.94, P=0.021). Montelukast appeared to be significantly less effective than salmeterol for controlling asthma symptoms and preventing exacerbations over 12 weeks (twice as many patients had exacerbations in the montelukast group, P=0.006) but, over 48 weeks, the proportion of patients who suffered exacerbations did not differ significantly between groups.1
This systematic review1 adds to previous concerns4 about the safety of LABAs. However, it should be considered in the context of other studies on the safety of both LABAs and leukotriene receptor antagonists (LTRAs) in asthma (see also related MeReC Blogs at www.npci.org.uk/blog/). For example, a Cochrane Review (11 RCTs, n=6,030) found that there was a similar risk of overall adverse effects between LABAs and LTRAs in adults with moderate asthma inadequately controlled on low doses of ICS. However, the confidence interval for severe adverse effects was wide and requires further investigation in a larger study.5 It is worth noting that LTRAs have been associated with Churg Strauss syndrome in some patients.6 For further details see the related MeReC Rapid Review Blog. (www.npci.org.uk/blog/?p=115)
| Panel 2: CHM advice on using LABAs in chronic asthma.3 |
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In the management of chronic asthma, LABAs should:
only be added if regular use of standard-dose ICS has failed to control asthma adequately
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not be initiated in patients with rapidly deteriorating asthma
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be introduced as a low dose and the effect properly monitored before considering a dose increase
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be discontinued in the absence of benefit
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be reviewed as clinically appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved.
Patients should be asked to report any deterioration in symptoms following initiation of a LABA.
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- Joos S, Miksch A, Szecsenyi J, et al. Montelukast as add-on therapy to inhaled corticosteroids in the treatment of mild to moderate asthma: a systematic review. Thorax 2008;63:453—62.
- Scottish Intercollegiate Guidelines Network and British Thoracic Society. British guideline on the management of asthma: a national clinical guideline. May 2008. Accessed from: www.sign.ac.uk/pdf/sign101.pdf on 18/06/08
- Medicines and Healthcare products Regulatory Agency. Asthma: long-acting b2 agonists. Accessed from: www.mhra.gov.uk/Safetyinformation/Generalsafety informationandadvice/Product-specificinformationandadvice/Asthma/index.htm on 27/05/08
- Nelson HS, Weiss ST, Bleecker ER, et al. The Salmeterol Multicenter Asthma Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest 2006;129:15-26
- Ducharme FM, Lasserson TJ, Cates CJ. Long-acting beta2-agonists versus anti-leukotrienes as add-on therapy to inhaled corticosteroids for chronic asthma. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003137. DOI: 10.1002/14651858.CD003137.pub3. Accessed from: www.mrw.interscience.wiley.com on 18/06/08
- Nathani N, Little MA, Kunst H, et al. Churg Strauss syndrome and leukotriene antagonist use: a respiratory perspective. Thorax May 2008 (online first) doi: 10.1136/thx.2007.093955. Accessed from: http://thorax.bmj.com on 27/05/08
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