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BTS/NICE/SIGN guideline for asthma 2024: Diagnosis,

monitoring and chronic asthma management. How does this
compare to GINA 2024?
Kevin Gruffydd-Jones1 ✉

The British BTS/NICE/SIGN Asthma Guideline was launched in November 2024 and represents a major shift in asthma diagnosis and
management in the United Kingdom. The British Guideline places emphasis on markers of eosinophilic inflammation as initial key
diagnostic tests whereas GINA places emphasis on test of reversible airflow limitation. Both documents acknowledge that there is
no one “gold-standard” test and, especially in areas of the world where the is limited or delayed access to tests, the IPCRG “jigsaw
puzzle” approach to asthma diagnosis may he particularly useful. The BTS/NICE/SIGN guideline provides strong economic evidence
to support the GINA strategy approach of single anti-inflammatory-reliever (AIR) and Maintenance and Reliever (MART) therapies as
the cornerstone of asthma management in people age 12 and over.
npj Primary Care Respiratory Medicine (2025)35:22 ; https://doi.org/10.1038/s41533-025-00425-x
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INTRODUCTION DIAGNOSIS OF ASTHMA IN ADULTS, YOUNG PEOPLE AND

The National Institute for Health and Clinical Excellence (NICE) CHILDREN AGE 5–16 (BTS/NICE/SIGN) AND IN ADULTS,
launched the first joint Guideline for asthma diagnosis, monitoring ADOLESCENTS AND CHILDREN AGE 6–11(GINA)
and chronic asthma management with the Scottish Intercollegiate Both BTS/NICE/SIGN and GINA documents emphasise that a
Guideline Network (SIGN) and British Thoracic Society (BTS)in diagnosis of asthma should be made on basis of a characteristic
November 20241. Prior to this date BTS/SIGN and NICE had history and confirmed by objective evidence. However their
produced separate guidelines with differing recommendations in recommendations for objective testing differ significantly.
some areas. This article compares the key areas of diagnosis and
BTS/NICE/SIGN: Emphasises tests for eosinophilic airway inflam-
pharmacological management in the BTS/NICE/SIGN Guideline mation such as Fractional Exhaled Nitric Oxide (FeNO), blood
with the Global Initiative for Asthma (GINA) Strategy report 20242 eosinophil counts and (in children) skin-prick testing.
and the implications for international primary respiratory care. GINA: Focuses on identifying variable expiratory airflow limita-
tion, primarily using spirometry with bronchodilator reversibility2.
The recommended tests, criteria for positivity and recom-
mended sequence of testing are shown in Fig. 1.
METHODOLOGY AND SCOPE
FeNO testing has moderate sensitivity (reflecting the number of
The GINA Strategy report was first produced in 1995, updated false negative results) in children and adults and high specificity
annually since 2002 and provides a comprehensive review of (reflecting a low number of false positive results)4. The order of
acute and chronic asthma across a range of severities. The 2024 diagnostic tests recommended by BTS/NICE/SIGN is largely based on
NICE/BTS/SIGN Guideline, principally, as the title suggests, focuses economic analysis derived from United Kingdom costs. However, as
on diagnosis, monitoring and chronic asthma management. It is pointed out in the GINA strategy document, the sensitivity of FENO
important to note that management of acute and chronic severe is reduced in smokers1 and obese individuals. Also it has
asthma is excluded. questionable utility in identifying non-eosinophilic asthma which
Updated relevant clinical evidence is reviewed by the GINA may account for 48% adults with asthma5. Evidence regarding the
scientific committee (composed of respiratory interested physi- diagnostic value of bronchodilator testing, particularly in children,
cians) based on criteria2 developed by the National Heart, Lung remains surprisingly limited. The evidence shows that bronchodi-
and Blood Institute in the USA. The BTS/NICE/SIGN Asthma lator reversibility has high specificity, but low sensitivity in adults4.
Guideline Committee is composed of multidisciplinary members (for example may be normal when a patient is asymptomatic) Peak
(such as primary and secondary care physicians, nurses and flow variability also shows low sensitivity, but has very high
pharmacists) and includes patient members. Evidence is analysed specificity and is readily available in primary care internationally.
and recommendations made using NICE methodology3 which Peak flow variability is defined as the mean daily variability of
significantly, in contrast to GINA, places additional emphasis on twice daily peak flow readings taken over a 2-week period. Daily
economic data, particularly cost-effectiveness. A critical value is variability is calculated as highest-lowest reading/mean daily
the cost of an intervention expressed as the cost per Quality- reading x100%.
adjusted life year (QALY) An intervention with a cost per-QALY of However, this method does rely on the reliability of patient
less than 20,000 pounds sterling (24,000 Euros) is considered as readings and the mean variability is time-consuming to calculate
being cost-effective. manually in a short consultation. However, calculators are

Warminster Primary Health Care Centre, Warminster, England. ✉email: [email protected]

1

Published in partnership with Primary Care Respiratory Society UK

 K Gruffydd-Jones
2
BTS/NICE/SIGN / 20241 GINA 20242
ADULTS CHILDREN ADULTS AND

& YOUNG PEOPLE >16 AGE 5-16 CHILDREN AGE t 6

FeNO>50ppb or blood FeNO>35ppb BDRt12% and 200ml (adults)

eosinophils “outside of andt12%(children)
local range” or t20% rise in PEFR (t13%
children) if spirometry not
available.

PEFR variability >10% adults

and >10% children
BDRt 12% and 200ml BDRt12% FEV-1 or t
ort10% predicted FEV-1 10% predicted FEV-1

4 week trial of inhaled

PEFR variability t 20% if PEFR variabilityt10%
spirometry delayed or not if spirometry delayed
available or not available
or rise in FEV-1t 12% and
200ml (adults) or t12%
(children)
1234567890():,;

test to house dust

mite or raised IgE
and blood
eosinophils >109/l

REFER TO RESPIRATORY SPECIALIST

atory Volume in 1 second

BDR: Bronchodilator reversibility PEFR; Peak Expiratory Flow Rate

Fig. 1 Objective tests for asthma in primary care and diagnostic criteria. (in sequence if the previous test is negative).

available on line which can significantly shorten the process. relatively patient unfriendly and not readily available in
(https://www.asthmaandlung.org.uk/healthcare-professionals/ primary care.
adult-asthma/diagnosis-testing/perf-calc). It is good practice to record the basis of diagnosis in the
Pragmatically, but without evidence, both GINA and BTS/NICE/ medical records.
SIGN recognise that reversibility of peak expiratory flow rate
(PEFR) post-bronchodilator ≥20% (>15% in children GINA) during
an acute attack can be used as a confirmatory diagnostic test. DIAGNOSIS OF ASTHMA IN CHILDREN UNDER 5 (BTS/NICE/
As highlighted, no single test serves as a “gold-standard” test for SIGN) AND UNDER 6 (GINA) IN PRIMARY CARE
asthma diagnosis and in many parts of the world, including the It is generally accepted that a diagnosis of asthma in a young child
United Kingdom, there are problems in accessing objective tests is difficult and should be strictly questioned under the age of 2
such as FeNO. when an alternative diagnosis is more likely.
There is agreement that a diagnosis of asthma should be based A diagnosis of asthma is suggested by the presence of:
on a characteristic history, exam and backed up by objective tests ●
where possible. However, where access to objective tests is limited Characteristic variable symptoms of recurrent wheeze, breath-
then a more pragmatic approach is needed. The International lessness or cough with multiple triggers (other than just with
Primary Care Group(IPCRG) has produced a consensus document viral infections), a family or past history of atopic disease,
“The ‘jigsaw puzzle’ approach” to building a diagnostic picture of absence of symptoms to suggest an alternative diagnosis (e.g.
asthma in primary care over time6 which offers a pragmatic failure to thrive).
● A positive trial of Inhaled Corticosteroids (ICS).
solution to the lack of universal availability of recommended tests.
It emphasises that there is no one gold standard objective test and
a diagnosis may not be able to made in a single consultation, but ○ Beclometasone or equivalent7 to 50–100 mcg daily
over time. In particular if an initial test is negative then it may need delivered standard aerosol particle metered -dose-
to be repeated when the patient is symptomatic. Methacholine inhaler(MDI)plus spacer with mask is given twice a day
challenge testing has high specificity and sensitivity, but is for 8–12 weeks. The ICS is then withdrawn.

npj Primary Care Respiratory Medicine (2025) 22 Published in partnership with Primary Care Respiratory Society UK
 K Gruffydd-Jones
3
NICE/BTS/SIGN GINA

Low-Dose Low-dose
ICS/Formoterol ICS/Formoterol
combination inhaler combination inhaler
for symptom relief for symptom relief

Low-dose Low-dose ICS/formoterol as

ICS/formoterol as maintenance and reliever
maintenance and therapy (MART)
reliever therapy (MART)

Medium -dose ICS/ Medium-dose

formoterol as IC/Formoterol as MART
MART

compliance good refer.

a LAMA or LTRA

“REFER FOR ASSESSMENT OF

PHENOTYPE “
REFER TO “SPECIALIST
ASTHMA CARE”

LTRA=Leukotriene receptor Antagonist Reflects stepping down when stable

Fig. 2 Preferred pharmacological management. Preferred pharmacological management of asthma in adults and adolescents (12 and over
GINA)1 and adults and young people (12 and over BTS/NICE/SIGN)2.

○ A trial is deemed positive if there is symptomatic traditional ICS plus SABA reliever therapy. In patients with
improvement whilst the child is on the ICS and there is moderate asthma, regular maintenance and as-needed reliever
symptomatic worsening when the ICS is withdrawn. therapy (MART) with budesonide/formoterol further reduced
exacerbations compared to traditional therapy with maintenance
If the child remains symptomatic and has not responded to the
ICS or ICS/long-acting beta-2 agonist (LABA) plus on-demand
ICS then referral to a respiratory paediatrician is recommended.
SABA12. As a result, GINA recommends a major shift in asthma
The BTS/NICE/SIGN Guideline also recommends that any pre-
management from maintenance ICS with SABA reliever therapy to
school child with an admission to hospital or 2 or more admissions
to an emergency department with wheeze within a 12- month ICS/formoterol as single reliever therapy (AIR) in mild asthma and
period should be referred to a respiratory paediatrician and that as maintenance and reliever therapy(MART) in more symptomatic
objective tests are carried out when the child reaches the age of 5. patients.
The BTS/NICE/SIGN Guideline group has also carried out an
economic analysis of the interventions and has found that AIR and
PHARMACOLOGICAL MANAGEMENT IN PEOPLE WITH MART are “dominant” i.e. more effective and cost less, han
ASTHMA AGE 12 AND OVER corresponding SABA therapy alone or maintenance ICS or ICS/
The 2019 GINA Strategy8 heralded a major shift in asthma LABA plus SABA therapy.
management amongst concerns about the overuse of short-acting This analysis gives major support by BTS/NICE/SIGN for the
Beta -2 agonists increasing the risk of severe asthma GINA recommendations and shows that AIR and MART therapy are
exacerbations9. not only effective,but also cost-effective. (albeit based on United
A large-scale randomised controlled trial10 demonstrated the Kingdom costs).
superiority of as-needed inhaled anti-inflammatory reliever(AIR) GINA and BTS/NICE/SIGN both recommend similar preferred
therapy using low-dose budesonide/formoterol in reducing management pathways and are shown in Fig. 2. Initial treatment
asthma exacerbations compared to short-acting beta-2 agonists should be commenced with AIR therapy if symptoms are relatively
(SABA) alone. Similarly, a large real -world study11 showed that AIR infrequent and with low or medium -dose MART if symptoms are
therapy significantly reduced severe exacerbations compared to more persistent, there is night waking or post-exacerbation,

Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2025) 22
 K Gruffydd-Jones
4

NICE/BTS/SIGN
GINA

Twice-daily “paediatric low - “Low dose”ICS whenever

SABA taken
beta-2 agonist(SABA) as
needed .

“Low dose”regular daily ICS

Consider paediatric low-dose and SABA for relief of
maintenance and reliever with symptoms
therapy (MART) ICS/formoterol

Consider adding LTRA to

ICS plus SABA if MART
Regular daily “Low dose”
not tolerated
ICS-LABA or “medium dose
Consider paediatric moderate ICS” or very low-dose ICS -
dose MART formoterol MART

REFER TO A SPECIALIST IN ASTHMA

CARE REFER “FOR EXPERT
ADVICE”

ICS dose: Beclometasone or equivalent via

dry powder inhaler12 ICS doses: Beclometasone or
equivalent via dry powder inhaler 12
Paediatric -low-dose=100mcg-200mcg/day
Low dose= 100-200mcg/day
Paediatric -Moderate dose: 300-400mcg/day
Medium dose=>200-400mcg /day

LTRA=Leukotriene receptor antagonist Reflects step-up and step-down

Fig. 3 Preferred pharmacological management. Preferred pharmacological management of asthma in children age 6–11(GINA)2 and
children age5–11(NICE/BTS/SIGN)1.

although the evidence for the efficacy of this treatment approach The recommended pharmacological management by GINA and
is relatively lacking. BTS/NICE/SIGN is shown in Fig. 3. The GINA approach is always to
They both emphasise the need for checking factors such as use inhaled corticosteroids in addition to bronchodilator when the
adherence, inhaler technique, trigger factors and diagnosis before child is symptomatic, progressing to regular ICS and SABA as
escalating therapy and also considering of stepping -down needed and MART with increased asthma severity. The BTS/NICE/
therapy when a patient is “stable’ (after 3 months-GINA). SIGN approach advocates regular ICS and SABA as-needed for
However, there are some differences: mild asthma progressing to MART therapy. Both strategies
GINA recommends an alternative treatment pathway (“Track 2”) recommend low-dose MART therapy as an initial treatment for
to AIR and MART therapies, based on the traditional maintenance highly symptomatic children.
ICS and SABA relief therapy. However there is no Track 2 in the There are limited studies on the use of MART in this age group13
NICE/BTS/SIGN guidance for people with asthma age 12 and over. although an economic analysis was carried out by NICE which
GINA does not recommend adding LTRA or LAMA to moderate- shows that MART therapy is cost-effective. At the time of writing
dose MART (≤ 800 mcg per day of Beclometasone or equivalent7 (December 2024) MART is not licensed for younger children in the
via DPI or standard-particle MDI before specialist referral. United Kingdom. In view of the concerns about the effects of
However, BTS/NICE/BTS suggest trying these options before SABA therapy without concomitant ICS in adults the GINA
referral unless FeNO is raised. (suggesting poor adherence with approach of always giving a form of ICS (either separately or in
ICS or a need for additional anti-eosinophilic inflammatory drugs) combination with bronchodilator) with relief medication does
Overall the NICE/BTS/SIGN Guideline for management of seem sensible although evidence to support this is limited14
asthma in people age 12 and over gives support for the GINA
approach of single ICS/formoterol AIR and MART therapy as the
core asthma treatment for chronic asthma management. How- SUMMARY
ever, this may not be applicable in lower economy countries The GINA Strategy 2024 and BTS/NICE/SIGN Guideline for asthma
where availability and cost of combination ICS/LABA inhalers may 2024 both emphasise the importance of making a diagnosis of
be problematic. In these case GINA’s alternative treatment asthma in school-age children, young people and adults on the
pathway centred around maintenance ICS and relief SABA use basis of a characteristic history, confirmed by objective tests. BTS/
may be more relevant. NICE/SIGN place an emphasis on markers of eosinophilic

npj Primary Care Respiratory Medicine (2025) 22 Published in partnership with Primary Care Respiratory Society UK
 K Gruffydd-Jones
5
inflammation such as FeNO and blood eosinophil levels whilst 12. Sobieraj, D. M. et al. Association of inhaled corticosteroids and long-acting
GINA emphasises the use of tests of reversible expiratory flow. β-agonists as controller and quick relief therapy with exacerbations and symp-
None of these tests has both high sensitivity and specificity and tom control in persistent asthma: A systematic review and meta-analysis. JAMA
repeat testing or testing by a different method may be needed. In 19, 1485–1496 (2018).
13. Bisgaard, H. et al. Budesonide/formoterol maintenance plus reliever therapy : a
areas where access to objective tests is restricted the IPCRG
new strategy in paediatric asthma. Chest 130, 1733–1743 (2006).
“jigsaw puzzle” approach can be particularly helpful. 14. Martinez, F. D et al. Use of beclomethasone diproprionate as rescue treatment for
In children age 5–12 with asthma there is a diminishing role of children with mild persistent asthma (TREXA) a randomised double-blind pla-
SABA alone as reliever therapy and an emerging role for MART. cebo-controlled trial. Lancet 377, 650–657 (2011).
Clinical and economic evidence reviewed by BTS/NICE/SIGN has
added further weight to the GINA recommendation that single
inhaler ICS/Formoterol on an as needed basis (AIR) and as ACKNOWLEDGEMENTS
maintenance and reliever therapy (MART) is now the cornerstone. Any opinions expressed in this article are those of the author alone and do not
of pharmacological asthma management in adults and young necessarily reflect those of the BTS/NICE/SIGN Asthma Guidelines Committee.
people 12 and over.
AUTHOR CONTRIBUTIONS
DATA AVAILABILITY The corresponding author had the idea for the article and is the sole contributor.
No datasets were generated or analysed during the current study.

Received: 6 December 2024; Accepted: 18 March 2025; COMPETING INTERESTS

Published online: 11 April 2025 Dr Gruffydd-Jones has spoken on behalf and acted as an advisor to GSK and Astra
Zeneca, He was a member of the BTS/NICE/SIGN Guidelines Committee.

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© The Author(s) 2025, corrected publication 2025

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