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To respond to the letter from Dr Sharvill, the NICE asthma guideline published in 2017 is contentious.1 It is driven by cost minimization and not by clinical need and does not recognize the limited availability of FeNO testing in the UK let alone primary care. It has caused much confusion as it differs markedly from other approaches.2 Recommendations written by clinicians, such as SIGN/BTS3 or GINA4 are more relevant and clinically useful. GINA is updated annually.
With regards to the clinical conundrum presented, the allergy to cat-dander, which is described here, is a classical Type-1 allergic response. Currently there appears to be no licensed allergen immunotherapy licensed for Fel d 1, the dominant allergen, in the UK. In the absence of immunotherapy, the best strategies are avoidance or pharmacotherapy. The patient described clearly has asthma in response to cat-dander. Pre-emptive use of a rapid acting/inhaled corticosteroid combination medication (not a medication containing salmeterol) prior to the visit and for any symptoms during and after the visit would probably be the most appropriate approach. The patient should probably be assessed when asymptomatic, by two weeks of twice daily peak flow readings to determine whether there is a low level background asthma which if present should be addressed (personal view).
References1. NICE. Asthma: diagnosis, monit...Show MoreCompeting Interests: None declared. - Page navigation anchor for Short acting B agonists and asthmaShort acting B agonists and asthma
Having initially worked in an era when we were told we were missing asthma (so called cough variant asthma then) we move to a time of over diagnosis and NICE guidelines to prove or disprove such as unavailable FeNO concentrations, and risk of other labels such as silent reflux ...
There is no doubt that overuse of SABA's is dangerous, costly (especially if ventolin is used or substituted by the pharmacy) and environmentally harmful but what does the author suggest for a person who only wheezes on exposure to cats such as when visiting a relative. A standby SABA or a LAMA/ICS noting they may not be used for months or years on end and then just once or twice
Competing Interests: None declared.