Contemporaneous International Asthma Guidelines Present Differing Recommendations: An Analysis

Table 2

Guideline criteria, levels of evidence, and papers cited for suboptimal asthma control (excluding children).

Criteria	CTS 2012	GINA 2012	BTS 2012
Daytime symptoms	>3 days per week	>2 times per week	>2 times per week
Exacerbations	More than “mild or infrequent exacerbations”^1	Any exacerbation^2	Exacerbation requiring oral corticosteroids in the last two years
Reliever requirements	>3 doses/week^3	>2 times/week	>2 times/week
Lung function	FEV1 or PEF <90% personal best	FEV1 or PEF <80% predicted or personal best	No criterion
Diurnal variation	PEF diurnal variation ≥10%^4	No criterion	No criterion
Sputum eosinophils	Sputum eosinophils ≥2-3%^5	No criterion	No criterion
Night-time symptoms	≥1 night/week	Any	≥1 night/week
Activity level	Any limitation in physical activity	Any limitation of activities	No criterion
Work/school absence	Any	No criterion	No criterion
Level of evidence^6	For controller initiation/escalation related to sputum eosinophils: evidence 1B (others not addressed)	For controller initiation related to “symptom frequency” or “periodic worsening”: evidence B (others not addressed)	For controller initiation (all criteria): evidence B
		For controller escalation (any criteria): “This is a working scheme based on current opinion and has not been validated”	For controller escalation (any criteria): none indicated
Papers cited	For controller initiation/escalation: references limited to sputum eosinophil recommendation	For controller initiation related to “symptom frequency” or “periodic worsening”:	For controller initiation (all criteria):
		O’Byrne et al. AJRCCM 2001 [41]; Pauwels et al. Lancet 2003 [42]; Zeiger et al. Resp Med 2004 [43]	O’Byrne et al. AJRCCM 2001 [41]; Pauwels et al. Lancet 2003 [42]
		For controller escalation: none	For controller escalation: none

The CTS guideline also adds: “In…adults presenting with an asthma exacerbation requiring a short course of systemic steroids, daily low- to moderate-dose ICS should be initiated as maintenance long-term therapy” (no level of evidence, no citations provided).
GINA guidelines include a footnote in their “Levels of Asthma Control” table which qualifies uncontrolled asthma with a note that any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
The CTS guideline includes the use of a reliever to prevent or treat exercise-induced symptoms in its weekly limit.
Listed criterion for good control is PEF diurnal variation <10–15%.
Listed criterion for good control is sputum eosinophils <2-3%; this criterion is only recommended in patients ≥18 years of age with moderate to severe asthma who are assessed in specialist centers.
See Tables 4, 5, and 6 for a description of the evidence rating system used by each guideline.
FEV1 denotes forced expiratory volume in one second; PEF denotes peak expiratory flow.