Table 1.
Guideline recommendations for referral of adult asthma patients to a specialist
| Situations indicated for specialist referral | ||||
|---|---|---|---|---|
|
| ||||
| Guideline | Diagnostic uncertainty | High-risk patients | Corticosteroid treatment (high dose, long-term use and side effects) | Add-on specialist treatment |
| GINA: global strategy for asthma management and prevention (2016)5 | • Difficulty in confirming the diagnosis of asthma • Patient has symptoms of chronic infection or features suggesting a cardiac or other nonpulmonary cause (immediate referral recommended) |
• Persistent uncontrolled asthma or frequent exacerbations, or low lung function despite correct inhaler technique and good adherence with step 4 treatment (moderate or high-dose ICS/LABA) • Symptoms suggesting complications or subtypes of asthma • Patient has frequent asthma-related health care utilization • Any risk factors for asthma-related death |
• Evidence of, or risk of, significant treatment side effects • Step 5 treatment, referral for specialist investigation and consideration of add-on treatment • Need for long-term OCS use • Frequent courses of OCS (two or more courses a year) |
• Omalizumab or mepolizumab treatment for patients who are uncontrolled at step 4 (moderate or high-dose ICS/LABA) |
| AAAAI practice parameters for the diagnosis and treatment of asthma (1995)29 | • For identification of allergens or other environmental factors that may be causing the patients’ disease; patients with asthma must have access to a thorough etiologic evaluation and appropriate diagnostics | • For all asthmatic patients and, in particular, those with asthma that is difficult to control, consider a referral • Fatality-prone asthmatic patients requiring special planning, including monitoring of the patient’s course with regard to the need |
• When the patient requires multiple medications on a long-term basis • When frequent bursts of OCS or daily OCS are required • When there is a concern about the side effects that have occurred or may occur |
• NR |
| AAAAI consultation and referral guidelines (2011)29 | • Patients with respiratory symptoms suggestive of asthma, but with normal pulmonary function test for a methacholine challenge test | • Patients with asthma who require ED care for acute episode • Uncontrolled asthma • Severe asthma • Persistent asthma, particularly moderate-severe persistent asthma • Patients with potentially fatal asthma |
• Unacceptable side effects of medications | • Immunomodulator therapy (anti-IgE) |
| National Asthma Council Australia (2015)88 | • Diagnostics tests (FEV1 pre-/post-bronchodilator, reversible airflow limitation, FEV1/FVC less than the lower limit for age, bronchial provocation test) do not support asthma diagnosis • Poor lung function with few symptoms and after a 3-month trial of high-dose ICS |
• Uncontrolled asthma on ICS/LABA combination (moderate to high dose) • Difficult-to-treat asthma • If poor lung function persists with a few symptoms after 3 months of higher dose ICS |
• NR | • NR |
| British Thoracic Society (2016)8 | • Diagnosis unclear | Patients with the following symptoms: • Persistent nonvariable breathlessness; • Monophonic wheeze or stridor; • Prominent systemic features (myalgia, fever, weight loss); • Chronic sputum production; • Chest X-ray shadowing; • Marked blood eosinophilia (>1×109/L); • Poor response to asthma treatment at step 4 prior to proceeding to step 5 • Severe asthma attack |
• Receiving high-does ICS should be under specialist care • Continuous or frequent use of oral steroids |
• Omalizumab treatment in severe and difficult allergic asthma patients who are on high-dose ICS and LABA (>6 years of age) |
| Canadian Thoracic Society Guideline Update: Diagnosis and management of asthma in preschoolers, children and adults (2012)50 | • NR | • Children (6–12 years of age) who fail to achieve control on a medium dose of ICS • Uncontrolled asthma in individuals >12 years of age who are on an ICS/LABA combination |
• In children and adults, the use of high doses of ICS due to possible significant side effects • In all age groups, frequent courses of OCS should prompt referral to a specialist |
• Omalizumab considered for patients >12 years of age with asthma poorly controlled despite high doses of ICS and appropriate add-on therapy, with or without OCS |
| GEMA (2009)10 | • NR | • Patients with difficult-to-control asthma should normally be controlled at specialized hospital centers by experienced medical personnel • When attacks are severe and/or complications are suspected, patients must be referred to a hospital ED • A history of high-risk attacks • Failure to respond to treatment, patients must be referred to a hospital ED |
• NR | • NR |
| Ireland asthma control in general practice (2012) | • Diagnosis is in doubt | • Post-hospitalization, if patient is uncontrolled at step 3 (GINA) | • NR | • NR |
| Japanese guideline for adult asthma (2011)6 | • Diagnosis is challenging | • Patients with underlying diseases such as AIA, CSS, other systemic vasculitis, and allergic bronchopulmonary aspergillosis • Long-term treatment (ICS, ICS/LABA, LTRA and omalizumab) is challenging |
• NR | • Long-term treatment with omalizumab is challenging |
| NAEPP (2007)9 | • Signs and symptoms are atypical or there are problems in differential diagnosis • Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy, complete pulmonary function studies, provocative challenge and bronchoscopy) • Other conditions complicate diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, VCD, GERD and COPD) |
• Patients who had a life-threatening asthma exacerbation or hospitalization as a result of an exacerbation • Patients who have difficulties achieving or maintaining control of asthma (goals of asthma therapy after 3–6 months of treatment) and patient is deemed unresponsive to treatment by a physician • Patient requires additional education and guidance on complications of therapy, problems with adherence or allergen avoidance • Patient requires step 4 care or higher (step 3 for children 0–4 years of age) • Consider referral if patient requires step 3 care (step 2 for children 0–4 years of age) • Other conditions complicate asthma (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, VCD, GERD and COPD) |
• Patient has required more than two bursts of OCS in 1 year | • NR |
| South African guidelines for the management of chronic asthma in adolescents and adults (2007)12 | • Diagnosis is in doubt | • Increasing severity and treatment (step 4–5) • Poor control despite intensive treatment • Recurrent exacerbations >2 per month • Recent discharge following admission for severe exacerbation |
• OCS dependence • Significant corticosteroid side effects |
• NR |
| Singapore Ministry of Health clinical practice guidelines on asthma management (2008)7 | • Diagnosis is in doubt | Adults • Patients who do not achieve good asthma control despite step 4 level of treatment have refractory asthma and should be reviewed by a specialist • Severe food allergy • Refractory patients who do not have good asthma control despite step 4 (medium or high-dose ICS plus one or more “add-on drug”) |
Adults • Prolonged high daily dose of ICS |
• NR |
Abbreviations: AAAAI, Academy of Allergy Asthma and Immunology; AIA, aspirin-induced asthma; COPD, chronic obstructive pulmonary disease; CSS, Churg Strauss syndrome; ED, emergency department; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; GEMA, Spanish Guideline on Management of Asthma; GERD, gastroesophageal reflux disease; GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; IgE, immunoglobulin E; LABA, long-acting beta agonist; LTRA, leukotriene receptor antagonist; NAEPP, National Asthma Education and Prevention Program; NR, not reported; OCS, oral corticosteroid; VCD, vocal cord dysfunction.