Asthma - Stable Management

Management of adult patients aged children aged ≥ 12 years with newly diagnosed asthma NICE

Step 1

a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
- this is termed anti-inflammatory reliever (AIR) therapy
if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
- start treatment with low-dose MART (maintenance and reliever therapy, see below)
- treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)

Step 2

a low-dose MART
- MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required

Step 3

a moderate-dose MART

Step 4

check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE
- if either of these is raised, refer to a specialist in asthma care
- if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
- if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)

Step 5

refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA

Algorithm showing pharmacological management of asthma in people aged 12 years and over

Transferring people aged 12 and over from other treatment pathways

There will be many people whose asthma was managed according to the previous guidelines that present with uncontrolled asthmatic symptoms. The guidelines give advice on how these people should be switched: NICE

Existing asthma treatment	New asthma treatment
SABA as required only	Low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy)
SABA as required + regular low-dose ICSSABA as required + regular low-dose ICS/LABASABA as required + regular low-dose ICS + LTRASABA as required + regular low-dose ICS/LABA + LTRA	Regular low-dose regular ICS/formoterol combination inhaler (MART therapy)
SABA as required + regular moderate-dose ICSSABA as required + regular moderate-dose ICS/LABASABA as required + regular moderate-dose ICS + LTRA or LAMASABA as required + regular moderate-dose ICS/LABA + LTRA or LAMA	Regular moderate-dose MART therapy
Treatment regime containing a high-dose ICS	Refer to a respiratory specialist

LTRA ⇒ Montelukast;

LAMA ⇒ Tiotropium (Respimat device)