muscarinic receptor antagonist, or modified-release
theophylline p. 169.
If there is no response to the LABA, discontinue it and
increase the dose of the inhaled corticosteroid 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 try adding a
leukotriene receptor antagonist or a long-acting muscarinic
receptor antagonist.h
High-dose inhaled corticosteroids and further add-on treatment
gBTS/SIGN ( 2016 ) recommend that if control remains
inadequate on a combination of short-acting beta 2 agonist as
required, a medium dose of inhaled corticosteroid, plus an
additional drug, usually a LABA, to consider the following
interventions:
.increase the inhaled corticosteroid to a high-dose—with
high doses of inhaled corticosteroid via a pressurised
metered dose inhaler (pMDI), a spacer should be used, or
.add a leukotriene receptor antagonist, or
.add modified-release theophylline p. 169 ,or
.Add tiotropium.
If a trial of a further add-on treatment is ineffective, stop the
drug (or in the case of increased dose of inhaled
corticosteroid, reduce to the original dose) and refer to
specialist care.h
Continuous or frequent use of oral corticosteroids
gBTS/SIGN ( 2016 ) recommend adding a regular oral
corticosteroid (prednisolone p. 442 ) at the lowest dose to
provide adequate control (under specialist care) in patients
with very severe asthma uncontrolled on high-dose inhaled
corticosteroids, and who have also tried (or are still
receiving) a LABA, a leukotriene receptor antagonist, or
modified-release theophylline p. 169 .h
Monoclonal antibodies and immunosuppressants
gBTS/SIGN ( 2016 ) recommend, that under specialist
initiation, immunosuppressants such as methotrexate p. 543
[unlicensed], and monoclonal antibodies such as
omalizumab p. 164 (for severe persistent allergic asthma),
and mepolizumab and reslizumab (in adults for severe
eosinophilic asthma), may be considered in patients with
severe asthma to achieve control and reduce the use of oral
corticosteroids.hSee mepolizumab, omalizumab p. 164 ,
and reslizumab National funding/access decisions.Child over 5 years
For children over 5 years, NICE ( 2017 ) treatment
recommendations for children apply to children aged
5 – 16 years and child over 16 years treatment
recommendations apply to those aged 17 years and over.
Whereas, for children over 5 years, BTS/SIGN ( 2016 )
treatment recommendations for children apply to
children aged 5 – 12 years and child over 16 years
treatment recommendations apply to those aged over
12 years.
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 children with asthma. For those with
infrequent short-lived wheeze, occasional use of reliever
therapy may be the only treatment required. Children 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 ( 5 – 16 years) as paediatric low, moderate, or
high. BTS/SIGN ( 2016 ) instead define inhaled
corticosteroid doses for children ( 5 – 12 years) as very
low, low, or medium, and for children over 12 years as
low, medium or high (refer to individual guidelines for
inhaled corticosteroid dosing information).gA paediatric low dose of inhaled corticosteroid should
be started as maintenance therapy in children 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 ) instead recommend starting a very low
dose (child 5 – 12 years) or a low dose (child over 12 years) of
inhaled corticosteroid in children presenting 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, or 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 paediatric low dose of
inhaled corticosteroid as maintenance therapy, consider a
leukotriene receptor antagonist (such as montelukast p. 165
or zafirlukast p. 166 [unlicensed in under 12 years]) in
addition to the inhaled corticosteroid, and review the
response to treatment 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 ) in children over 12 years, or a LABA or a
leukotriene receptor antagonist in children 5 – 12 years, as
initial add-on therapy to inhaled corticosteroids if asthma is
uncontrolled.h
Additional add-on therapy
gIf asthma is uncontrolled on a paediatric low dose of
inhaled corticosteroid and a leukotriene receptor antagonist
as maintenance therapy, consider discontinuation of the
leukotriene receptor antagonist and initiation of a LABA in
combination with the inhaled corticosteroid.
If asthma remains uncontrolled on a paediatric low dose
of inhaled corticosteroid and a LABA as maintenance
therapy, consider changing to a MART regimen
(Maintenance And Reliever Therapy—a combination of an
inhaled corticosteroid and fast-acting LABA such as
formoterol in a single inhaler) with a paediatric 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 paediatric low dose of inhaled corticosteroid as
maintenance, consider increasing to a paediatric 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 on a paediatric moderate
dose of inhaled corticosteroid as maintenance with a LABA
(either as MART or afixed-dose regimen), consider seeking
advice from an asthma specialist and the following options:
.increasing the inhaled corticosteroid dose to a paediatric
high dose as maintenance (this should only be offered as
part of afixed-dose regimen, with a short-acting beta 2
agonist as reliever therapy), or
.a trial of an additional drug, such as modified-release
theophylline p. 169.
BTS/SIGN ( 2016 ) instead recommend that if the child is
gaining some benefit from addition of a LABA but control
remains inadequate, continue the LABA and increase the148 Airways disease, obstructive BNFC 2018 – 2019
Respiratory system3