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

• Salamol CFC-free pressurised metered dose aerosol inhalation 100 micrograms/ metered inhalation (pMDI)
• Salamol Easi-breathe or Airomir Autohaler breath-actuated aerosol inhalation 100 micrograms/ metered inhalation (BAI)

Terbutaline

• Bricanyl Turbohaler Dry powder inhaler 500 micrograms/ metered inhalation (DPI)

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:

• 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

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.

Easyhaler Budesonide
(Budesonide)

• Dry power inhaler (DPI)
  • 100 micrograms/ metered inhalation – 2 puffs twice a day
  • 200 micrograms/ metered inhalation – 1 puff twice a day

Pulmicort Turbohaler
(Budesonide)

• Dry powder inhaler (DPI)
  • 100 micrograms/ metered inhalation – 2 puffs twice a day
  • 200 micrograms/ metered inhalation – 1 puff twice a day

Kelhale
(Beclomethasone dipropionate extrafine)

• Aerosol inhalation 50 micrograms/ metered inhalation (pMDI) – 2 puffs twice a day

Qvar
(Beclomethasone dipropionate extrafine)

• Aerosol inhalation 50 micrograms/ metered inhalation (pMDI) – 2 puffs twice a day
• Autohaler breath-actuated aerosol inhalation 50 micrograms/ metered inhalation (BAI) – 2 puffs twice a day
• Easi-breathe breath-actuated aerosol inhalation 50 micrograms (BAI) – 2 puffs twice a day

Clenil Modulite
(Beclomethasone dipropionate)

• Aerosol inhalation 100 micrograms/ metered inhalation (pMDI) – 2 puffs twice a day

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:

• using inhaled beta₂ agonist 3 times/week or more

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.

Initial add-on therapy

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

• Fostair NEXThaler (DPI) 100/6 – 1 puff twice a day
• Luforbec (pMDI) 100/6 – 1 puff twice a day

Budesonide / formoterol

• Fobumix Easyhaler (DPI) 160/4.5 – 1 puff twice a day
• Symbicort Turbohaler (DPI) 200/6 – 1 puff twice a day
• DuoResp Spiromax (DPI) 160/4.5 – 1 puff twice a day

Note: DuoResp Spiromax 160/4.5 and Fobumix Easyhaler 160/4.5 are equivalent to the Symbicort Turbohaler 200/6 preparation. DuoResp Spiromax and Fobumix Easyhaler strengths refer to the delivered dose whereas the Symbicort Turbohaler strengths refer to the total dose contained in each actuation.

Fluticasone propionate /salmeterol

• Seretide Accuhaler (DPI) 100/50 – 1 puff twice a day
  
• Avenor (pMDI) 50/25 - 2 puffs twice a day

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:

• using inhaled beta₂ agonist 3 times/week or more

Maintenance and Reliever Therapy (MART)

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?

• Usually designed for adults (aged 18 or over, but see below)
• Not fully controlled asthma and in need of reliever medication
• Asthma exacerbations in the past requiring medical intervention

General guidance for all regimes:

• Take a daily maintenance dose of the inhaler and in addition take the inhaler as needed in response to symptoms. Patients should be advised to always carry their inhaler with them.
• Patients requiring frequent use of rescue inhalations daily, should be strongly recommended to seek medical advice. Their asthma should be reassessed and their maintenance therapy should be reconsidered.

What are the MART options?

Fostair NEXThaler 100/6 (DPI) or Luforbec 100/6 (pMDI)
(Beclometasone dipropionate (extrafine) and formoterol fumarate)

• Fostair NEXThaler and Luforbec are recommended for adults 18 years and above
• Maintenance dose is 1 inhalation twice daily
• 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken.
• The maximum daily dose is 8 inhalations.

Fobumix Easyhaler 80/4.5 or 160/4.5 (DPI) or Symbicort Turbohaler 200/6 (DPI) or DuoResp Spiromax 160/4.5 (DPI)
(Budesonide and formoterol fumarate)

• DuoResp Spiromax and Fobumix Easyhaler are recommended for adults 18 years and above
• Symbicort Turbohaler is recommended for adults and adolescents 12 years and above
• Maintenance dose is 2 inhalations per day, given either as one inhalation in the morning and evening, or as 2 inhalations in either the morning or evening
• A maintenance dose of 2 inhalations twice daily may be appropriate for some patients (Fobumix Easyhaler 160/4.5, Symbicort Turbohaler 200/6 and DuoResp Spiromax 160/4.5 only)
• Plus 1 additional inhalation as needed in response to symptoms
• A total daily dose of more than 8 inhalations is not normally needed; however, a total daily dose of up to 12 inhalations could be used for a limited period

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 there is no improvement when a LABA is added, stop the LABA and try:
  • Montelukast, or
  • an increase to medium dose of ICS, see (Inhaled Corticosteroid Dose Comparison in Asthma), or
  • 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 the low-dose ICS see (Inhaled Corticosteroid Dose Comparison in Asthma) and add montelukast, or tiotropium, or modified release theophylline, or
  • continue the LABA and increase to medium dose of ICS see (Inhaled Corticosteroid Dose Comparison in Asthma)

Note: montelukast treatment should be trialled – if no benefit is seen after 4 weeks, montelukast should be discontinued and alternative treatment options discussed with the patient.

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:

• add montelukast, or
• increase the ICS to high dose see (Inhaled Corticosteroid Dose Comparison in Asthma), or
• add modified release theophylline, or
• add tiotropium (Spiriva Respimat is licensed for this indication)

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), and discuss alternative treatment options with the patient.

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:

• Use daily prednisolone tablets in the lowest dose providing adequate control
• Maintain high dose ICS (total beclometasone 1600 micrograms daily or equivalent, see Inhaled Corticosteroid Dose Comparison in Asthma)
• 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.

See section 6.3.2 Glucocorticoid therapy

The following treatments may be recommended for use in secondary care:

Benralizumab as an add-on therapy, is recommended as an option for treating severe eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with high-dose inhaled corticosteroids and long-acting beta-agonists. See NICE TA565 (March 2019)

Mepolizumab as an add-on to optimised standard therapy, is recommended as an option for treating severe refractory eosinophilic asthma in adults. See NICE TA671 (February 2021)

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)

Reslizumab as an add-on therapy, is recommended as an option for the treatment of severe eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with high-dose inhaled corticosteroids plus another drug. See NICE TA479 (October 2017)

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.

• Discuss with the patient the potential risks and benefits of decreasing maintenance therapy.
• Agree with the patient how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and a follow-up with a healthcare professional.
• Consider decreasing maintenance therapy when a patient's asthma has been controlled with their current maintenance therapy for at least 3 months.
• Decrease the dose of ICS by approximately 25-50% each time.
• Take symptom severity, treatment side effects, and time on current dose, benefit gained and patient preference into account when deciding which drug to step down and at what rate.
• Regular review of patients as treatment is stepped down is important.

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 One Devon website here

See section 3.1.4 Combination inhalers, 3.2 Corticosteroids, Inhaled Corticosteroid Dose Comparison in Asthma

***under review***

• 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 (SABA) inhaler becomes progressively less effective at relieving symptoms
• Dosage: 30-40mg once daily prednisolone for 5-7 days. Stop or taper down.

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.

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 3.1.1 Adrenoceptor agonists, 6.3.2 Glucocorticoid therapy, 3.1.5 Peak flow meters, inhaler devices and nebulisers

***under review***

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 affect control. See 3.1.5 Peak flow meters, inhaler devices and nebulisers

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 an In-Check device. If the patient is unable to use a device satisfactorily an alternative should be found
• 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
• Technique should be assessed by a competent healthcare professional
• 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.
• Choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).

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 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.

Placebo inhalers can be obtained from the NHS Devon Medicines Optimisation Team, please contact: d-icb.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: Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over (March 2008)

NICE NG80: Asthma: Diagnosis, monitoring and chronic asthma management

NHS Devon further information and resources for health care professionals

National Review of Asthma Deaths