NICE Technology Appraisal Guidance - No. 38 Inhaler devices for routine treatment of chronic asthma in older children (aged 5-15 years)

NICE Technology Appraisal Guidance - No. 38 Inhaler devices for routine treatment of chronic asthma in older children (aged 5-15 years)

The Health Technology Board for Scotland (HTBS) is delivering this National Institute for Clinical Excellence (NICE) Guidance to health professionals in NHSScotland with the following authoritative Comment on its use in Scotland.  This HTBS Comment must be read in conjunction with the NICE Guidance.

HTBS advises that the NICE Technology Appraisal Guidance - No. 38 Inhaler devices for routine treatment of chronic asthma in older children (aged 5-15 years) is as valid for Scotland as for England and Wales. It is linked to this page for your information.

The NICE recommendations are shown below.

• 1.1 It is recommended that in addition to therapeutic need (including chosen drug and dose), the following factors be taken into account when choosing inhaler devices for individual children with chronic asthma:
  • the ability of the child to develop and maintain an effective
  technique with the specific device
  • the suitability of a device for the child and carer’s lifestyles,
  considering factors such as portability and convenience
  • the child’s preference for and willingness to use a particular device.
• 1.2 The general recommendations in 1.1 should be taken into account when considering the following specific guidance:
  1.2.1 A press-and-breathe pressurised metered dose inhaler (pMDI) and suitable spacer device is recommended as the first-line choice for the delivery of inhaled corticosteroids as part of regular planned daily therapy, with the aim of maximizing benefits of preventive therapy in attaining good asthma control, and minimising potential systemic absorption. Where clinicians believe that an individual child’s adherence to the press-and-breathe pMDI and spacer combination is likely to be so poor as to undermine effective asthma control, other alternative devices (taking account of the factors outlined in 1.1
  and evidence of equivalence of clinical effectiveness) should be considered, bearing in mind the need to minimise the risks of systemic absorption of corticosteroids.
  1.2.2 In the case of other inhaled drugs, primarily bronchodilators, it is recommended that a wider range of devices be considered to take account of their more frequent spontaneous use, the greater need for portability, and the clear feedback that symptom response provides to the device user. In such circumstances the factors outlined in 1.1 are likely to be of greater importance in choosing a device.
• 1.3 Where more than one device satisfies the considerations outlined above in a particular child, it is recommended that the device with the lowest overall cost (taking into account daily required dose and product price per dose) should be chosen.
• 1.4 On selection of an inhaler device, it is important that consideration is given to other aspects of asthma care that influence the effective delivery of inhaled therapy, including:
  • individual practical training in the use of the specific device
  • monitoring of effective inhaler technique and adherence to therapy
  • regular (i.e. no less than annual) review of inhaler needs, which may
  change over time with increasing age.

HTBS anticipates that implementing this NICE Guidance in Scotland will have the following implications for NHSScotland:

Service Issues

• It is anticipated that the Scottish Intercollegiate Guidelines Network (SIGN), jointly with the British Thoracic Society (BTS), will publish revised guidelines on asthma in September 2002 (http://www.sign.ac.uk/). 
• Attention is drawn to the NICE Guidance No. 10 Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma published in August 2000 (http://www.nice.org.uk/).
• Health professionals and NHS organisations with responsibility for treating children aged 5-15 years with chronic asthma should review their current practice in line with this guidance on inhaler devices. 
• Health professionals involved in the prescribing, supply, and administration of inhaler devices to children should be appropriately trained, be able to explain about the full range of inhalers available and provide effective training in the proper use of devices.
• To enable health professionals to audit their own compliance with this guidance it is recommended that local protocols are adapted or, if none exist, developed and implemented locally.  Appendix D of the NICE Guidance outlines the technical details of the use of specific criteria for audit purposes.  In addition, NHS Boards, Trusts, LHCCs and practice teams may wish to monitor their prescribing of inhaler types.
• Scotland should participate in the recommended further research on inhaler devices (NICE Guidance Section 6).

Impact

• Data from the 1998 Scottish Health Survey (Shaw A, McMunn A and Field J (eds). 2000.  The Scottish Health Survey 1998: Volume 1: Findings. Edinburgh: The Stationery Office) shows a prevalence of diagnosed asthma among children aged 2-15 years of 16% for girls and 19% for boys.  The prevalences for the 2-6, 7-10 and 11-15 age groups are similar and therefore the 2-15 age group prevalence is a reasonable estimate of the prevalence in children aged 5-15.
• The estimated Scottish population of children aged 5-15 is 316,154 girls and 331,683 boys.  This gives figures in Scotland for those with diagnosed asthma of 50,585 girls and 63,020 boys. 
• It is difficult to predict the impact of this advice (except for spacer devices) because the budget impact is very sensitive to device prescribing patterns, as acquisition costs of inhalers delivering the same class of drug at the same dose vary substantially (NICE Guidance Section 5.1).  Consequently, the estimated current inhaler costs, and the estimated costs of additional spacer devices for Scotland, are shown below.
• The NICE Guidance assumed that in England and Wales 60% of those diagnosed with asthma use press-and-breathe pMDIs, 17% use breath-actuated pMDIs, and 23% use DPIs.  Assuming there is a similar treatment pattern in Scotland, that all children with diagnosed asthma receive bronchodilators, and that 80% receive corticosteroids, the estimated current annual acquisition costs in Scotland for inhaler devices for children aged 5-15 years is £3.6m (NICE Guidance Sections 5.2 and 5.3). 
• The cost of introducing a press-and-breathe pMDI and suitable spacer as the first line choice for delivering inhaled corticosteroids would increase the rate of prescribing of such spacer devices from 20% to 100% and the total acquisition costs of spacers would increase by £0.1m for NHSScotland (NICE Guidance Sections 5.5).
• The wider resource implications of implementing this advice in relation to training and audit, noting in particular Sections 1.4 and 7.3 of the NICE Guidance, are not costed in this Comment.

NHSScotland should take account of this Comment from HTBS and ensure that
recommended drugs or treatments are made available to meet clinical need.

This HTBS Comment is the result of a consideration of possible contextual differences in Scotland, according to the following categories:

• Principles and values of NHSScotland
• Epidemiology (frequency and distribution)
• Structure and provision of services in Scotland
• Other implications for the Scottish Health Service.

No important differences were identified for this NICE Technology Appraisal Guidance. The process used is available on request or from this site.

An Understanding HTBS Advice is also being distributed on this topic and is available from this website.
HTBS would like to thank NICE for its cooperation in delivering this Comment. HTBS is also grateful to the experts in Scotland who provided input to this Comment.