Contemporaneous International Asthma Guidelines Present Differing Recommendations: An Analysis

Figure 1

Recommended therapeutic escalation steps and levels of evidence, by guideline. (1) 1A when compared to a LABA; 1B when compared to a LABA/ICS combination. (2) Although it reports an extensive literature review for the recommendation to escalate from a low dose ICS by adding a LABA in step 3 (as opposed to increasing to a medium ICS dose or adding an LTRA), the CTS guideline does not provide a level of evidence nor any reference for initiation at a low ICS dose per se. (3) The BTS/SIGN guideline did not provide a level of evidence nor references for the higher dose approach. In a separate section, authors acknowledged that many patients will benefit more from add-on therapy than from increasing doses above 200 mcg/d BDP. (4) This was an alternative treatment option described in the text only, with no specific level of evidence. (5) The CTS guideline stated that patients uncontrolled on a fixed-dose ICS/LABA should be switched to the SMART approach in lieu of increasing the ICS dose of the combination. However, in a separate section, the guideline also noted that “if asthma remains uncontrolled on the combination of an ICS and LABA…consider the addition of an LTRA,” suggesting that either switching to the SMART approach or adding an LTRA would be acceptable. (6) The GINA guideline stated that an increase from medium to high dose provides “relatively little additional benefit,” which seems to contradict the BTS/SIGN approach in both this step and in step 2. See Appendix for a description of the evidence rating system used by each guideline. BDP denotes beclomethasone dipropionate; BTS/SIGN denotes British Thoracic Society/Scottish Intercollegiate Guidelines Network; CTS denotes Canadian Thoracic Society; GINA denotes Global Initiative on Asthma; LABA denotes long-acting beta agonist; LOE denotes level of evidence; SMART denotes Symbicort maintenance and reliever therapy.