To respond to the letter from Dr Sharvill, the National Institute for Health and Care Excellence (NICE) asthma guideline published in 2017 is contentious.1 It is driven by cost-minimisation and not by clinical need, and does not recognise the limited availability of FeNO testing in the UK, let alone in primary care. It has caused much confusion as it differs markedly from other approaches.2 Recommendations written by clinicians, such as the Scottish Intercollegiate Guidelines Network (SIGN)/British Thoracic Society (BTS)3 or Global Initiative for Asthma (GINA),4 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 2 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).
- © British Journal of General Practice 2022