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Research and Guideline updates
Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE
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  • Published on:
    Comparison of ICS doses
    • John White, Consultant Respiratory Physician York Teaching Hospital NHS Foundation Trust
    • Other Contributors:
      • James Y Paton, Reader in Paediatric Respiratory Medicine
      • Robert Niven, Consultant Respiratory Physician
      • Hilary Pinnock, Professor of Primary Care Respiratory Medicine

    We are grateful to Dr. Duerden and Dr. Levy for their comments on our paper which highlight the difficulty of comparing doses of ICS steroids when there is no gold standard comparator. Our aim in compiling Table 1 was to point out that the NICE table does not allow for the greater potency of HFA FP compared to HFA BDP. We were concerned that this was a significant safety issue especially in children [1]. In our efforts to simplify this message, we had not fully explained or allowed for some of the other variables.

    1. Dr. Levy is correct to point out that the original GINA table (used by NICE) of “Low, medium and high daily doses of inhaled corticosteroid for children 6-11 years” has a statement below indicating that the table is not a table of “dose equivalency”, the term we used in Table 1, but of “estimated clinical comparability”.

    2. The GINA table (but not NICE) also has a footnote explaining the inclusion of beclometasone dipropionate CFC (BDP CFC) as a comparison with older literature. CFCs (chlorofluorocarbons), as propellants in metered dose inhalers, were phased out under the Montreal Protocol and were replaced by HFAs (hydrofluorolakanes). However, CFC BDP is still often used as the reference standard when comparing ICS in terms of their potency.

    3. Most newer HFA ICSs have been formulated to be equipotent with the CFC ICS they were replacing. As one example, the BTS/SIGN table includes the proprietary HFA BPD, Clenil modulite, commonly us...

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    Conflict of Interest:
    None declared.
  • Published on:
    Inaccuracy regarding Inhaled Corticosteroid equivalence
    • Mark L Levy, Part time GP Respiratory Lead Harrow CCG; Member of the BTS/SIGN Acute Guideline Group; Board Member of GINA

    While I agree this paper draws out most of the important issues related to the NICE guideline, I would like to point out that there are inaccuracies regarding the statements and table related to 'dose equivalences' in the GINA document.
    In fact reference to equivalence in your article is explicitly contradicted by the statement immediately below GINA table 3-6, which states that 'this is not a table of equivalence, but of estimated clinical comparability'. (1)
    Furthermore the GINA table also takes into account the potential for side-effects. For example, BDP HFA causes more adrenal suppression than FP HFA at the same dose. (2)
    Of course this is going to get even more complicated with the number of generics now available, as they cannot be assumed to be equivalent to the original product, due to the impact of the inhaler device and additives.

    (2) Fowler, S. J., Orr, L. C., Wilson, A. M., Sims, E. J. and Lipworth, B. J. (2001), Dose-response for adrenal suppression with hydrofluoroalkane formulations of fluticasone propionate and beclomethasone dipropionate. British Journal of Clinical Pharmacology, 52: 93-95. doi:10.1046/j.0306-5251.2001.bjcp.1399.x

    Conflict of Interest:
    In the last year I have accepted payment for lectures, (mainly on Asthma Deaths and preventing these) from TEVA and NAPP and Chiesi Pharmaceutical companies; I have served on advisory boards for Boeringer Ingelheim and Astra Zeneca. I currently serve on a Drug Safety Monitoring Board for Cheisi.