Asthma - adult treatment guidance

Guide the patient in the use of asthma self-management plans (see above) and use of peak flow information.

Inhaled short acting beta₂ agonists as required, See section: 3.1.1 Adrenoceptor agonists

Consider moving to Step 2 if:

• using inhaled beta₂ agonist 3 times/week or more
• symptomatic 3 times/week or more
• waking one night a week
• One or more exacerbations requiring oral corticosteroid in the last two years

Continue the use of asthma self-management plans (see above) and use of peak flow information.

Inhaled corticosteroids are the most effective preventer drug for adults and older children for achieving overall treatment goals.

Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors.

In mild to moderate asthma, starting at high doses of ICSs and stepping down confers no benefit. Start patients at a dose of inhaled corticosteroids appropriate to the severity of disease. A reasonable starting dose, taken twice a day, of inhaled corticosteroids will usually be low dose (total beclometasone 400 micrograms daily or equivalent) for adults.

See section: 3.2 Corticosteroids

Consider initial add-on therapy, moving to Step 3 if:

• using inhaled beta₂ agonist 3 times/week or more

Initial add-on therapy

Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors.

Add inhaled long acting beta agonist (LABA) to low-dose inhaled corticosteroid (ICS)

In asthma, a LABA should not be prescribed without ICS preventer treatment. Combination LABA/ICS devices are recommended to ensure LABA is given with appropriate ICS dose.

Consider additional add-on therapy, if:

• using inhaled beta₂ agonist 3 times/week or more

Additional add-on therapies

If control remains poor on low-dose ICS plus a LABA, recheck the diagnosis, assess adherence to existing medication and check inhaler technique before increasing therapy. If more intense treatment is appropriate, then the following alternatives can be considered.

• If there is no improvement when a LABA is added, stop the LABA and try:
  • an increase to medium dose of ICS (beclometasone 800 micrograms/day or equivalent) if not already on this dose
  • an leukotriene receptor antagonist
  • tiotropium (Spiriva Respimat is licensed for this indication)
• If there is an improvement when a LABA is added but control remains inadequate:
  • continue the LABA and increase to medium dose of ICS (beclometasone 800 micrograms/day or equivalent) if not already on this dose, or
  • continue the LABA and the low-dose ICS (beclometasone 400 micrograms/day or equivalent) and add an leukotriene receptor antagonist or tiotropium, (as above), or a theophylline modified release

See sections: 3.1.4 Combination inhalers, 3.1.2 Antimuscarinic bronchodilators, 3.3.2 Leukotriene receptor antagonists (LTRAs), 3.1.3 Theophylline

If still symptomatic: Refer to secondary care

High dose inhaled corticosteroid (ICS) (total beclometasone 1600 micrograms daily or equivalent) should only be used after referring the patient to secondary care.

Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors.

In a small proportion of patients asthma is not adequately controlled on a combination of short-acting beta₂ agonist as required, medium-dose ICS, and an additional drug, usually a LABA.

If control remains inadequate on medium dose of an ICS (total beclometasone 800 micrograms daily or equivalent), plus a LABA, the following interventions can be considered:

• increase the ICS to high dose (total beclometasone 1600 micrograms daily or equivalent or
• add a leukotriene receptor antagonist or
• add a theophylline modified release or
• add tiotropium (Spiriva Respimat is licensed for this indication)

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).

Refer patient for specialist care

See sections: 3.1.4 Combination inhalers, 3.1.2 Antimuscarinic bronchodilators, 3.3.2 Leukotriene receptor antagonists (LTRAs), 3.1.3 Theophylline

Refer patient for specialist care

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 eliminate trigger factors.

Some patients with very severe asthma not controlled with high-dose ICS, and who have also been tried on or are still taking long-acting beta-agonists, leukotriene antagonists or theophyllines, require regular long-term steroid tablets.

For the small number of patients not controlled on high-dose therapies,

• Use daily prednisolone tablets in the lowest dose providing adequate control.
• Maintain high dose inhaled corticosteroid (ICS) (total beclometasone 1600 micrograms daily or equivalent)
• Consider other treatments to minimise use of oral steroids

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.

Omalizumab (secondary care only) 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

• Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient's preference should all be taken into account
• Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time
• For further information on stepping down treatments please see the respiratory information here

• Symptoms and peak flow get progressively worse each day
• Peak flow falls below 60% of the patient's best
• Morning symptoms persist until midday
• Maximum permitted therapy does not control symptoms
• Emergency nebuliser or intravenous bronchodilators are required
• Short acting beta₂ agonist inhaler becomes progressively less effective at relieving symptoms
• Dosage: 30-40mg daily prednisolone until peak flow returns to best. Stop or step down.

Important: Patient should be reviewed by a GP or Nurse within one month of commencing oral steroids

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.

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 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.

When choosing an inhaler device consider:

• The availability of the drug and dose in the specific device.
• The ability of the person to develop and maintain an effective technique with the specific device, this may depend on such factors as age, dexterity, coordination, and inspiratory flow. Inspiratory flow can be tested using, for example and an In-Check device. If the patient is unable to use a device satisfactorily an alternative should be found
• The suitability of the device to the person's (and carer's) lifestyles, considering such factors as portability and convenience.
• The person's preference for and willingness to use a particular device.
• Cost, choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).
• Good technique is essential in ensuring the correct use of inhaler devices. Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique. Reassess inhaler technique as part of structured clinical review

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.

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.

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)

CCG further information and resources for health care professionals

BTS/SIGN Full Guideline on the management of asthma (2016)

National Review of Asthma Deaths