Aims of treatment
The aim of treatment is to achieve control of asthma.
Complete control of asthma is defined as no daytime
symptoms, no night-time awakening due to asthma, no
asthma attacks, no need for rescue medication, no
limitations on activity including exercise, normal lung
function (in practical terms forced expiratory volume in
1 second (FEV 1 ) and/or peak expiratoryflow (PEF)> 80 %
predicted or best), and minimal side-effects from treatment.
In clinical practice, patients may choose to balance the aims
of asthma management against the potential side-effects or
inconvenience of taking medication necessary to achieve
perfect control.
Lifestyle changes
gWeight loss in overweight patients may lead to an
improvement in asthma symptoms. Parents with asthma
should be advised about the danger of smoking, to
themselves and to their children with asthma, and be offered
appropriate support to stop smoking. Breathing exercise
programmes (including physiotherapist-taught methods)
can be offered as an adjuvant to drug treatment to improve
quality of life and reduce symptoms.h
Management
gA stepwise approach aims to stop symptoms quickly
and to improve peakflow. Treatment should be started at the
level most appropriate to initial severity of asthma. The aim
is to achieve early control and to maintain it by stepping up
treatment as necessary and decreasing treatment when
control is good. Before initiating a new drug or adjusting
treatment consider whether diagnosis is correct, check
adherence and inhaler technique, and eliminate trigger
factors for acute attacks.
A self-management programme comprising of a written
personalised action plan and education should be offered to
all patients with asthma (and/or their family or carers).h
Recommendations on the management of chronic asthma
from theNational Institute for Health and Care Excellence
(NICE)—Asthma: diagnosis, monitoring and chronic asthma
management guidelines (NG 80 , November 2017 ), and British
Thoracic Society (BTS) and Scottish Intercollegiate Guidelines
Network (SIGN)—British guideline on the management of
asthma (SIGN 153 , September 2016 )differ significantly.
Recommendations in BNF publications are based on NICE
guidelines, and differences with BTS/SIGN ( 2016 ) have been
highlighted.
Child over 16 years
NICE ( 2017 ) treatment recommendations for child over
16 years apply to patients aged 17 years and over.
BTS/SIGN ( 2016 ) treatment recommendations for child
over 16 years are the same as those for patients over
12 years (see child over 5 years section).
Intermittent reliever therapy
gStart an inhaled short-acting beta 2 agonist (such as
salbutamol p. 156 or terbutaline sulfate p. 158 ), to be used as
required, in all patients with asthma. For those with
infrequent short-lived wheeze, occasional use of reliever
therapy may be the only treatment required. Patients using
more than one short-acting beta 2 agonist inhaler device a
month should have their asthma urgently assessed and
action taken to improve poorly controlled asthma.h
Regular preventer (maintenance) therapy
NICE ( 2017 )define inhaled corticosteroid doses for
children over 16 years as low, moderate, or high.
BTS/SIGN ( 2016 ) instead define inhaled corticosteroid
doses for children over 16 years as low, medium or high
(refer to individual guidelines for inhaled corticosteroid
dosing information).
gA low dose of inhaled corticosteroid should be started
as maintenance therapy in patients who present with any
one of the following features: using an inhaled short-acting
beta 2 agonist three times a week or more, symptomatic three
times a week or more, or waking at night due to asthma
symptoms at least once a week. BTS/SIGN (^2016 ) also
recommend initiation in patients who have had an asthma
attack in the last 2 years, and starting inhaled corticosteroids
at a dose appropriate to the severity of asthma.
BTS/SIGN ( 2016 ) recommend that inhaled corticosteroids
(except ciclesonide p. 162 ) should be initially taken twice
daily, however, the same total daily dose, taken once a day,
can be considered in patients with milder disease if good or
complete control of asthma is established. The dose of
inhaled corticosteroid should be adjusted over time to the
lowest effective dose at which control of asthma is
maintained.
BTS/SIGN ( 2016 ) recommend the prescribing of inhalers
by brand.h
Initial add-on therapy
gIf asthma is uncontrolled on a low dose of inhaled
corticosteroid as maintenance therapy, a leukotriene
receptor antagonist (such as montelukast p. 165 or
zafirlukast p. 166 ) should be offered in addition to the
inhaled corticosteroid, and the response to treatment
reviewed in 4 to 8 weeks.
BTS/SIGN ( 2016 ) instead recommend a long-acting beta 2
agonist (LABA—such as salmeterol p. 155 or formoterol
fumarate p. 154 ) as initial add-on therapy to inhaled
corticosteroids if asthma is uncontrolled.h
Additional add-on therapy
gIf asthma is uncontrolled on a low dose of inhaled
corticosteroid and a leukotriene receptor antagonist as
maintenance therapy, a LABA in combination with the
inhaled corticosteroid should be offered with or without
continued leukotriene receptor antagonist treatment,
depending on the response achieved from the leukotriene
receptor antagonist.
If asthma remains uncontrolled, offer to change the
inhaled corticosteroid and LABA maintenance therapy to a
MART regimen (Maintenance And Reliever Therapy—a
combination of an inhaled corticosteroid and a fast-acting
LABA such as formoterol in a single inhaler), with a low dose
of inhaled corticosteroid as maintenance. See budesonide
with formoterol p. 161 [not licensed in all age groups].
If asthma remains uncontrolled on a MART regimen with
a low dose of inhaled corticosteroid as maintenance with or
without a leukotriene antagonist, consider increasing to a
moderate dose of inhaled corticosteroid (either continuing a
MART regimen or changing to afixed-dose regimen of an
inhaled corticosteroid and a LABA, with a short-acting beta 2
agonist as reliever therapy).
If asthma is still uncontrolled in patients on a moderate
dose of inhaled corticosteroid as maintenance with a LABA
(either as MART or afixed-dose regimen), with or without a
leukotriene receptor antagonist, consider the following
options:
.increasing the inhaled corticosteroid dose to a high-dose
as maintenance (this should only be offered as part of a
fixed-dose regimen, with a short-acting beta 2 agonist used
as a reliever therapy), or
.a trial of an additional drug, for example, a long-acting
muscarinic receptor antagonist (such as tiotropium) or
modified-release theophylline p. 169 ,or
.seek advice from an asthma specialist.
BTS/SIGN ( 2016 ) instead recommend that if the patient is
gaining some benefit from addition of a LABA but control
remains inadequate, that the LABA be continued and the
dose of inhaled corticosteroid be increased to a medium-
dose, if not already on this dose. If increasing the dose of
inhaled corticosteroid is ineffective, consider continuing on
a low dose of inhaled corticosteroid and a LABA and try
adding a leukotriene receptor antagonist, or a long-actingBNFC 2018 – 2019 Airways disease, obstructive 147
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