dose of the inhaled corticosteroid to a low-dose (child
5 – 12 years) or medium-dose (child over 12 years), if not
already on this dose. If increasing the dose of inhaled
corticosteroid is ineffective, consider continuing a very low
dose (child 5 – 12 years) or low dose (child over 12 years) of
inhaled corticosteroid and a LABA and try adding a
leukotriene receptor antagonist, or modified-release
theophylline p. 169 , or long-acting muscarinic receptor
antagonist (in children over 12 years).
If there is no response to the LABA, discontinue it and
increase the dose of inhaled corticosteroid to a low-dose
(child 5 – 12 years) or medium-dose (child over 12 years), if
not already on this dose. If increasing the dose of inhaled
corticosteroid is ineffective, consider continuing on a very
low dose (child 5 – 12 years) or low dose (child over 12 years)
of inhaled corticosteroid and try adding a leukotriene
receptor antagonist or long-acting muscarinic receptor
antagonist (in children over 12 years).h
High-dose inhaled corticosteroids and further add-on treatment
gBTS/SIGN ( 2016 ) recommend that if control remains
inadequate on a combination of a short-acting beta 2 agonist
as required, a low dose (child 5 – 12 years) or medium dose
(child over 12 years) of inhaled corticosteroid, plus an
additional drug, usually a LABA, to consider the following
interventions:
.increase the inhaled corticosteroid to a medium-dose
(child 5 – 12 years) or high-dose (child over 12 years)—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 (in children over 12 years).
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 children
with very severe asthma uncontrolled on a medium dose
(child 5 – 12 years) or high dose (child over 12 years) of
inhaled corticosteroid, 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 (child over 6 years for severe persistent
allergic asthma) can be considered in children with severe
asthma to achieve control and reduce the use of oral
corticosteroids.hSee omalizumab p. 164 National
funding/access decisions.
Child under 5 years
Intermittent reliever therapy
gA short-acting beta 2 agonist (such as salbutamol p. 156 )
as reliever therapy should be offered to children under
5 years with suspected asthma. A short-acting beta 2 agonist
should be used for symptom relief alongside maintenance
treatment.
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 under 5 years as paediatric low or moderate.
BTS/SIGN ( 2016 ) instead define inhaled corticosteroid
doses for children under 5 years as very low (refer to
individual guidelines for inhaled corticosteroid dosing
information).
gConsider an 8 -week trial of a paediatric moderate
dose of inhaled corticosteroid in children presenting with
any of the following features: asthma-related symptoms
three times a week or more, experiencing night-time
awakening at least once a week, or suspected asthma that is
uncontrolled with a short-acting beta 2 agonist alone.
BTS/SIGN ( 2016 ) recommend the prescribing of inhalers
by brand.
After 8 weeks, stop inhaled corticosteroid treatment and
continue to monitor the child’s symptoms:
.if symptoms did not resolve during the trial period, review
whether an alternative diagnosis is likely;
.if symptoms resolved then reoccurred within 4 weeks of
stopping inhaled corticosteroid treatment, restart the
inhaled corticosteroid at a paediatric low-dose asfirst-line
maintenance therapy;
.if symptoms resolved but reoccurred beyond 4 weeks after
stopping inhaled corticosteroid treatment, repeat the
8 -week trial of a paediatric moderate dose of inhaled
corticosteroid.
BTS/SIGN ( 2016 ) instead recommend starting a very low
dose of inhaled corticosteroid as initial regular preventer
therapy 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. In children unable to take an inhaled
corticosteroid, a leukotriene receptor antagonist (such as
montelukast p. 165 ) may be used an alternative.h
Initial add-on therapy
gIf suspected asthma is uncontrolled in children under
5 years on a paediatric low dose of inhaled corticosteroid as
maintenance therapy, consider a leukotriene receptor
antagonist (such as montelukast p. 165 ) in addition to the
inhaled corticosteroid.
If suspected asthma is uncontrolled in children under
5 years on a paediatric low dose of inhaled corticosteroid and
a leukotriene receptor antagonist as maintenance therapy,
stop the leukotriene receptor antagonist and refer the child
to an asthma specialist.hDecreasing treatment
gConsider decreasing maintenance therapy when a
patient’s asthma has been controlled with their current
maintenance therapy for at least three months. When
deciding which drug to decreasefirst and at what rate, the
severity of asthma, the side-effects of treatment, duration on
current dose, the beneficial effect achieved, and the patient’s
preference, should be considered. Patients should be
regularly reviewed when decreasing treatment.
Patients should be maintained at the lowest possible dose
of inhaled corticosteroid. Reductions should be considered
every three months, decreasing the dose by approximately
25 – 50 % each time. Reduce the dose slowly as patients
deteriorate at different rates. Only consider stopping inhaled
corticosteroid treatment completely for people who are
using a paediatric or adult low dose inhaled corticosteroid
alone as maintenance therapy and are symptom-free.hExercise-induced asthma
gFor most patients, exercise-induced asthma is an
illustration of poorly controlled asthma and regular
treatment including inhaled corticosteroids should therefore
be reviewed. If exercise is a specific problem in patients
already taking inhaled corticosteroids who are otherwise well
controlled, consider adding either a leukotriene receptor
antagonist, a long-acting beta 2 agonist, an oral beta 2 agonist,
sodium cromoglicate p. 167 or nedocromil sodium p. 167 ,or
theophylline p. 169. An inhaled short-acting beta 2 agonists
used immediately before exercise is the drug of choice.hBNFC 2018 – 2019 Airways disease, obstructive 149
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