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For the management of asthma in children aged 12 years and under, refer to the guidance here.
The guidance below has been produced in collaboration with local specialists and is in line with that produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidance Network (SIGN).
Stepwise Asthma Management: Patients should start treatment at the step most appropriate to the initial severity of their asthma. Check concordance and reconsider diagnosis if response to treatment is unexpectedly poor. Move up to improve control as needed; move down to find and maintain lowest controlling step.
Self-Management Plan: All patients with asthma should be provided with a personalised asthma action plan (PAAP) that details their own triggers and current treatment, specifies how to prevent relapse, and when and how to seek help in an emergency. Self-management plans are widely available, including from Asthma UK.
Trial any change of therapy involving an inhaled corticosteroid (ICS) for at least 6 weeks. Once full control is achieved, which can take 3-6 months, consider reduction of therapy to lowest level that maintains control. Other therapy changes may show improvement in less than 6 weeks.
Be mindful of overuse of reliever inhalers. All asthma patients who have been prescribed more than 6 short-acting reliever inhalers in the previous 12 months should be considered for a review. Those patients prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review, as this is associated with an increased risk of asthma death (NRAD 2014). Medicines adherence, inhaler technique and self-management plans should be considered, and change made to the patient's treatment if required.
Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly; in addition, not all inhalers with the same primary ingredient are interchangeable due to differences in particle size.
Different products and doses are licensed for different age groups and some may be applicable only to older children or adults (aged 18 years and over). Prior to prescribing, the relevant summary of product characteristics (SPC) should be checked.
Key: Metered dose inhaler = (MDI); Dry powder inhaler = (DPI)
Guide the patient on the use of asthma self-management plans (see above) and use of peak flow information.
Adults with a diagnosis of asthma should be prescribed a short-acting bronchodilator to relieve symptoms. For those with infrequent short-lived wheeze, occasional use of reliever therapy may be the only treatment required.
Inhaled short acting beta2 agonists (SABA) as required
Salbutamol
Terbutaline
See section: 3.1.1 Adrenoceptor agonists, 3.1.5 Peak flow meters, inhaler devices and nebulisers
Be mindful of overuse of reliever Inhalers (see above).
Inhaled corticosteroids (ICS) are the most effective preventer drug for adults and older children for achieving overall treatment goals in asthma (see regular preventer therapy below).
Continue the use of asthma self-management plans (see above) and use of peak flow information. In addition, ensure an inhaled short-acting beta2 agonist is prescribed as a short term reliever therapy for all patients with symptomatic asthma (see intermittent reliever therapy above).
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer user, and eliminate trigger factors.
Inhaled corticosteroids (ICS) are the most effective preventer drug for adults and older children for achieving overall treatment goals in asthma.
Consider addition of an ICS, as a regular preventer therapy, if:
Start patients at a dose of inhaled corticosteroids appropriate to the severity of disease. A reasonable starting dose of ICS taken twice a day is low dose beclomethasone (total 400 micrograms daily) or equivalent. Suggested starting doses for inhaled corticosteroids are shown below. Adjust according to response.
Note: Beclomethasone inhalers are not interchangeable. Kelhale® and Qvar® are extra-fine particle formulations and are therapeutically equivalent. They are both approximately twice as potent as Clenil® Modulite®.
Pulmicort® Turbohaler®
(Budesonide)
Kelhale®
(Beclomethasone dipropionate extrafine)
Qvar®
(Beclomethasone dipropionate extrafine)
Clenil® Modulite®
(Beclomethasone dipropionate)
See section: 3.2 Corticosteroids, Inhaled Corticosteroid Dose Comparison in Asthma, 3.1.5 Peak flow meters, inhaler devices and nebulisers
Consider initial add-on therapy if:
Continue the use of asthma self-management plans (see above) and use of peak flow information.
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors.
Add inhaled long acting beta agonist (LABA) to low-dose inhaled corticosteroid (ICS) and prescribe as a combination inhaler. In asthma, do not prescribe a LABA without ICS preventer treatment.
Beclometasone dipropionate (extrafine) / formoterol
Budesonide / formoterol
Note: Duoresp® Spiromax® 160/4.5 is equivalent to the Symbicort® Turbohaler® 200/6 preparation. Duoresp® Spiromax® strengths refer to the delivered dose whereas the Symbicort® Turbohaler® strengths refer to the total dose contained in each actuation.
Fluticasone propionate /salmeterol
See section: 3.1.4 Combination inhalers, Inhaled Corticosteroid Dose Comparison in Asthma, 3.1.5 Peak flow meters, inhaler devices and nebulisers
Consider additional add-on therapy, if:
Some people with asthma can be prescribed Maintenance and Reliever Therapy (MART). This treatment regime involves the use of a single combination inhaler containing an ICS and LABA, which is used as both the daily preventer and reliever of symptoms as required.
Who might get benefits from Maintenance and Reliever Therapies?
General guidance for all regimes:
What are the MART options?
Fostair® 100/6 (pMDI) and Fostair NEXThaler ® 100/6 (DPI)
(beclometasone dipropionate (extrafine) and formoterol fumarate)
DuoResp® Spiromax® 160/4.5 (DPI) or Symbicort® Turbohaler® 200/6 (DPI)
(budesonide and formoterol fumarate)
See sections: 3.1.4 Combination inhalers, Inhaled Corticosteroid Dose Comparison in Asthma, 3.1.5 Peak flow meters, inhaler devices and nebulisers
If control remains poor on low-dose ICS plus LABA (combination inhaler), recheck the diagnosis, assess adherence to existing medication and check inhaler technique and spacer use before increasing therapy. If more intense treatment is appropriate, then the following alternatives can be considered:
If still symptomatic: Refer to secondary care
See sections: 3.1.4 Combination inhalers, 3.2 Corticosteroids,3.1.5 Peak flow meters, inhaler devices and nebulisers, 3.1.2 Antimuscarinic bronchodilators, 3.3.2 Leukotriene receptor antagonists (LTRAs), 3.1.3 Theophylline, Inhaled Corticosteroid Dose Comparison in Asthma
If still symptomatic: Refer to secondary care
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors.
In a small proportion of patients asthma is not adequately controlled on a combination of short-acting beta2 agonist (SABA) as required, medium-dose inhaled corticosteroid (ICS), and an additional drug, usually a long acting beta agonist (LABA).
If control remains inadequate on medium dose of an ICS (see Inhaled Corticosteroid Dose Comparison in Asthma), plus a LABA, the following interventions can be considered:
High dose ICS should only be used after referring the patient to secondary care.
If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS, reduce to the original dose).
See sections: 3.1.4 Combination inhalers, 3.2 Corticosteroids, 3.1.5 Peak flow meters, inhaler devices and nebulisers, 3.1.2 Antimuscarinic bronchodilators, 3.3.2 Leukotriene receptor antagonists (LTRAs), 3.1.3 Theophylline, Inhaled Corticosteroid Dose Comparison in Asthma
Secondary care should be involved in the management of patients requiring long term oral steroids.
The aim of treatment is to control asthma using the lowest possible doses of medication.
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors.
Some patients with very severe asthma not controlled with high-dose inhaled corticosteroids (ICS), and who have also been tried on or are still taking long-acting beta-agonists (LABA), montelukast or theophyllines, may require regular long-term steroid tablets.
For the small number of patients not controlled on high-dose therapies:
Patients on long-term steroid tablets (for example, longer than three months) or requiring frequent courses of steroid tablets (for example three to four per year) will be at risk of systemic side effects; monitoring may be required.
See section6.3.2 Glucocorticoid therapy
The following treatments may be recommended for use in secondary care:
Mepolizumab as an add-on to optimised standard therapy, is recommended as an option for treating severe refractory eosinophilic asthma in adults. See NICE TA431 (January 2017)
Omalizumab is recommended as an option for treating severe persistent confirmed allergic IgE mediated asthma as an add on to optimised standard therapy in people aged 6 years and older. See NICE TA278 (April 2013)
See section 3.4.2 Allergen Immunotherapy
Patients should be maintained at the lowest possible dose of inhaled corticosteroid (ICS), which provides control.
Review and update the person's asthma treatment plan when decreasing maintenance therapy.
Further information on stepping-down combination ICS/ long-acting beta-agonist (LABA) inhaler therapy in adults over 18 with asthma can be found on the NHS Devon CCG website here
See section 3.1.4 Combination inhalers, 3.2 Corticosteroids, Inhaled Corticosteroid Dose Comparison in Asthma
Important: Patient should be reviewed by a GP or Nurse within one month of commencing oral steroids
See section 6.3.2 Glucocorticoid therapy
All patients with asthma should be provided with a personalised asthma action plan (PAAP) that details their own triggers and current treatment, specifies how to prevent relapse and when and how to seek help in an emergency. Self-management plans are widely available, including from Asthma UK.
Refer to hospital any patients with features of acute severe or life-threatening asthma.
Give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain a SpO2 level of 94–98%. Do not delay oxygen administration in the absence of pulse oximetry but commence monitoring of SaO2 as soon as it becomes available.
Use high-dose inhaled beta2 agonists as first-line agents in patients with acute asthma and administer as early as possible. Metered dose inhalers with spacers can be used for patients with asthma attacks other than life threatening. Patients should be advised where possible to use a large-volume spacer device.
Give steroids in adequate doses to all patients with an acute asthma attack. Steroid tablets are as effective as injected steroids, provided they can be swallowed and retained. Prednisolone 40-50mg once daily, continued for at least five days or until recovery.
After asthma admission
Prior to discharge, follow up should be arranged with the patient's general practitioner or asthma nurse within two working days. Follow up should also be arranged with a hospital specialist asthma nurse or respiratory physician at about one month after admission.
Rescue medication: Consider giving a standby rescue course of oral prednisolone to patients who have experienced severe attacks or who live in geographically isolated areas. When to start should be detailed in the written management plan with advice to seek a medical review when treatment begins.
See section 6.3.2 Glucocorticoid therapy, 3.1.5 Peak flow meters, inhaler devices and nebulisers
A Pressurised Metered Dose Inhaler (pMDI), with or without a spacer, is the first choice delivery device. Consider alternatives if compliance and/or technique problems effect control. See 3.1.5 Peak flow meters, inhaler devices and nebulisers
When choosing an inhaler device consider:
Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using the same type of device to deliver preventer and reliever treatments may improve outcomes.
Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly; in addition, not all inhalers with the same primary ingredient are interchangeable due to differences in particle size.
The NHS Devon CCG Medicines Optimisation Team has produced a webpage which provides further respiratory information for patients and healthcare professionals; this information can be found here, and includes guides to inhaler techniques and checklists.
Advice on how to obtain placebo inhalers can be obtained from the NHS Devon CCG Medicines Optimisation Team, please contact: d-ccg.medicinesoptimisation@nhs.net
BTS/SIGN Full Guideline on the management of asthma (2016)
NICE TA131: Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years (November 2007)
NICE TA138: Asthma (in adults), corticosteroids (March 2008)
NICE NG80: Asthma: Diagnosis, monitoring and chronic asthma management
CCG further information and resources for health care professionals
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