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February 2020

NICE reverses advice on quadrupling ICS dose for children

NICE has reversed its previous recommendations to increase the dose of inhaled corticosteroids (ICS) for children experiencing deteriorating asthma control.

NICE guidelines previously recommended that an increased dose of ICS, such as quadrupling, for 7 days should be considered for children and young people who were previously using ICS when asthma control deteriorated. But new evidence indicates that this strategy may not reduce the rate of severe asthma exacerbations in children with mild-to-moderate asthma, and may have an adverse effect on growth.

NICE now recommends:

For children and young people aged 5 to 16 with a diagnosis of asthma, include advice in their self-management programme on contacting a healthcare professional for a review if their asthma control deteriorates.

For those in this age group who have not been taking their ICS consistently, explain that restarting regular use may help them to regain control of their asthma. The evidence for increasing ICS doses to self-manage deteriorating asthma control is limited.

In its review of the evidence, the guideline committee decided not to recommend changing the ICS dose if asthma control worsens – but conversely not to issue a ‘do not do’ recommendation because the latest evidence was not strong enough to support it.

Instead, the committee recommends that children should request a review of their self-management plan if their asthma is not responding to their asthma personalised action plan. This represents best clinical practice, that should normally be occurring but usually does not. The evidence review states: ‘Many children live with mild but frequent symptoms. These children are usually the ones who are most at risk of dying because of an exacerbation.’

The committee identified factors that may be contributing to deteriorating control.

  • Asthma reviews only occur annually. There may be wider issues that need addressing before the annual review date, such as:
    • poor inhaler technique
    • the prescribing of a different inhaler, and
    • changing factors in the child’s environment that may be precipitating recurring mild symptoms and/or poor control.

The committee also agreed that many self-managing children with asthma do not take their regular ICS, but that it was impossible for clinicians to know which children were non-adherent. This was another reason for children to have their self-management plan reviewed, as self-management programmes should include education. The recommendation was necessary because in primary care, few children are routinely monitored.

Finally, the committee noted that it was ‘unsatisfactory for children to be self-managing asthma using ever-increasing ICS maintenance doses which have little effect.’

NICE NG80. Evidence review A: increasing ICS treatment within supported self-management for children and young people (February 2020).

NICE NG80. Guideline update