Previous changes

March 2026 — minor update. Broken links have been amended, and the wording has been slightly changed in the section on the management of newly diagnosed asthma.

May 2025 — minor update. QOF indicators updated in line with the NHS England Quality and Outcomes Framework guidance for 2025/26. Prescribing information for ipratropium inhalers has been removed.  

April 2025 — minor update. Revised text in the prescribing section on the use specific types of inhalers to improve the clarity of the recommendations in line with NICE asthma guidance on MART and AIR therapies.

December 2024 to January 2025 — reviewed. A literature search was conducted in December 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has been updated in line with the joint BTS/NICE/SIGN guideline Asthma: diagnosis, monitoring and chronic asthma management NG245 [BTS/NICE/SIGN, 2024] and the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024]. The recommendations on diagnosis and management of asthma in all age-groups have been updated in line with the BTS/NICE/SIGN (2024) recommendations, including use of different objective tests to confirm the diagnosis depending on age-group, and prescribing initial treatment with anti-inflammatory reliever (AIR) therapy or maintenance and reliever therapy (MART) using an inhaled corticosteroid (ICS)/formoterol combination inhaler for people aged 12 years and over first-line, and to consider a MART regime with an ICS/formoterol combination inhaler for children aged 5 to 11 years (off-label indication in this age-group).

July 2024 — minor update. Updated prevalence data and replaced broken links. 

December 2023 — minor update. Recommendations relating to COVID-19 infection have been removed from this topic. Information about the onset of action of beta-2 agonists aligned to the manufacturers' Summary of Product Characteristics (SPC).

October 2023 — minor update. Revised the text on prescribing oral corticosteroids to all people with an acute exacerbation of asthma.

August 2023 — minor update. Change to the management section to clarify that quadrupling inhaled corticosteroids in acute asthma is relevant for the management of adults. 

June 2023 — minor update. The term 'muscarinic agent' in the prescribing information section has been changed to 'muscarinic antagonist' for clarification. 

April 2022 — minor update. Drug interactions with azithromycin amended to include hydroxychloroquine and chloroquine, in line with the manufacturers' SPC.

May 2021  — minor update. A typographical error has been corrected.

October 2020 — minor update. A typographical error has been corrected.

April 2020 — minor update. The topic has been updated to take into account the latest British Thoracic Society (BTS) guideline on macrolide use. 

April 2020 — minor update. The frequency of use of Alvesco inhaled corticosteroid pressurized metered dose inhaler has been updated.

April 2020 — minor update. New management scenario created to provide information regarding COVID-19. 

February 2020 — minor update. Topic updated in line with the National Institute for Health and Care Excellence (NICE) guideline Asthma: diagnosis, monitoring and chronic asthma management (2020).

November 2019 — minor update. Quality Standards updated.

September 2019 — minor update. The topic has been updated to take into account recommendations in the latest BTS/SIGN guideline. 

April 2018 — minor update. Spiriva Respimat is now licensed as add-on maintenance bronchodilator treatment in people aged 6 years and older with severe asthma who experienced one or more severe asthma exacerbations in the preceding year.

March 2018 — reviewed. A literature search was conducted in March 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

February 2018 — minor update. A Cochrane systematic review Anti-IL5 therapies for asthma added to new evidence section. 

October to December 2016 — reviewed and updated. A literature search was conducted in October 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone restructuring. No major changes to the recommendations have been made.

December 2013 — minor update. A broken link to the Children's Asthma Control Test (ACT) has been fixed.

July 2013 — minor update. Links to the DVLA website have been updated.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

May 2013 — minor update. Minor change to the text to improve the clarity managing people awaiting hospital admission.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

April 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

March 2012 — minor update. A recommendation to advise people inhaling terbutaline via a turbohaler to rinse their mouth after each use to minimize systemic adverse effects has been added, following an update to the manufacturer's SPC. 

December 2011 — minor update. The black triangle has been removed from Serevent Evohaler^® (salmeterol cfc-free inhaler); prescriptions have been amended to reflect this.

June 2011 — annual updates from the British guideline on the management of asthma: a national clinical guideline by SIGN/BTS are now included. Pulmicort pMDI inhalers have been removed from this topic as they have been discontinued. The 2011/2012 QOF indicators and the 2010/2011 QIPP options for local implementation have been added to this topic.

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

February 2011 — minor update. The range of dry powder inhaler devices included as prescriptions has been updated. 

December 2010 — minor update. The Flixotide Diskhaler^® (fluticasone) range has been discontinued. The prescription has been removed.

November 2010 — minor update. Information on fitness to drive from the Driver and Vehicle Licensing Agency (DVLA) guidance for medical practitioners At a glance guide to the current medical standards of fitness to drive has been added. 

September 2010 — minor update. The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a reminder to prescribers that, for most children, a daily dose of 24 micrograms formoterol is sufficient. 

March 2010 — minor update. All strengths of Beclazone^® inhalers have been discontinued. Prescriptions removed. Advice regarding switching from CFC beclometasone to CFC-free beclometasone added.

January 2010 — minor update. Ciclesonide (Alvesco^®) is no longer a black triangle product. Minor addition to text regarding drug interactions with theophylline. Issued in January 2010.

December 2009 — minor update. Clenil Modulite^® (beclometasone CFC-free) is no longer a black triangle product. Prescription updated. Issued in December 2009.

November 2009 — minor update. The Supporting evidence section on Symbicort Smart® has been reworded to make it clear that the data summarized are from a single Cochrane review. Issued in November 2009.

August 2009 — minor update. The annual updates from the British guideline on the management of asthma: a national clinical guideline by SIGN/BTS are now included. 

June 2009 — updated to include information and prescriptions for budesonide CFC-free pMDI. The Nebuhaler^® spacer device has been discontinued. The prescription has been replaced with the NebuChamber^® spacer device. 

May 2009 — minor update. The Quality and Outcomes Framework (QOF) indicators for stopping smoking that relate to asthma have been added to the Goals and outcome measures section. 

March 2009 — minor update. Flixotide^® 50 microgram diskhaler and all strengths of the Aerobec^® breath-actuated inhaler have been discontinued. Prescriptions removed. 

November 2008 — update to the diagnosis and assessment sections following the publication of the British guideline on the management of asthma: a national clinical guideline by SIGN/BTS. 

March 2008 — minor update to include advice from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of short-acting beta-2 agonists in people who have a history of heart disease. 

September to December 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. This CKS topic includes revisions in the 2007 update to the SIGN/BTS British Guideline on the management of asthma.

June 2007 — updated. Nebuhaler^® discontinued. Prescriptions replaced with Nebuhaler^® + mask, which continues to be available. Becotide® and Becloforte® discontinued.

May 2007 — updated. Becotide^® and Becloforte^® discontinued. Prescriptions removed. Issued in May 2007.

March 2007 — updated. Prescriptions and dosing information for Clenil Modulite^® (CFC-free beclometasone) and CFC-free formoterol included. Information on spacer device compatibilities also updated.

July to September 2006 — updated. Validated in December 2006 and issued in January 2007.

July 2006 — minor update. All strengths of Ventodisks^® (salbutamol dry powder Diskhaler^®) will be discontinued from the end of September 2006 and prescriptions have been removed. 

May 2006 — minor update. Prescriptions for CFC-free nedocromil and salmeterol pressurized metered dose inhalers have replaced those for CFC-containing inhalers. Information on changing to CFC-free inhalers included in Medicines Management. 

February 2006 — minor update. Volumatic^® spacer device re-introduced and prescriptions included; terbutaline pressurized metered dose inhalers have been discontinued and prescriptions removed. 

August 2005 — updated to include revisions in the 2005 update to the SIGN/BTS British Guideline on the Management of asthma, and the new CMO recommendations on the pneumococcal immunization programme. Volumatic^® spacer device discontinued and prescriptions removed; advice for using alternative spacer devices included. Validated in September 2005 and issued in November 2005.

August 2004 — updated to include revisions in the 2004 update to the SIGN/BTS British Guideline on the Management of Asthma. Validated in September 2004 and issued in November 2004.

April 2003 — reviewed. Validated in September 2003 and issued in October 2003. This guidance supersedes the CKS guidance Asthma — age under 5 years, which has been withdrawn.

April 2002 — reviewed and updated to incorporate Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years), technology appraisal guidance no. 38, issued by the National Institute for Health and Care Excellence (April 2002).

April 1999 — reviewed. Validated in July 1999 and issued in August 1999.

June 1998 — written.

New evidence

Evidence-based guidelines

• NICE (2025) 12 SQ-HDM SLIT for treating allergic rhinitis and allergic asthma caused by house dust mites. National Institute for Health and Care Excellence https://www.nice.org.uk [Free Full-text]
• AWMSG (2025) All Wales Adult Asthma Management and Prescribing Guideline. All Wales Medicines Strategy Group. [Free Full-text]

HTAs (Health Technology Assessments)

• NICE (2026) Digital technologies to support self-management of asthma: early-use assessment. National Institute for Health and Care Excellence. [Free Full-text]

Economic Appraisals

No new economic appraisals relevant to England since 1 December 2024.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 December 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 December 2024.

New policies

No new national policies or guidelines since 1 December 2024.

New safety alerts

No new safety alerts since 1 December 2024.

Changes in product availability

• New product, omlyclo (omalizumab) 150mg solution for injection pre-filled pen, is licensed for the treatment of allergic asthma. See more here.
• New product Exdensur (depemokimab) 100 mg/1 ml Solution for injection in a pre-filled pen. This monoclonal antibody targeting interleukin 5, administered twice-yearly, is licensed for use as an add-on treatment for asthma in adults & adolescents (≥12 year) & as an add-on treatment for severe chronic rhinosinusitis with nasal polyps in adults. See more here.
• New product: Omlyclo (omalizumab) 300 mg/2 ml Solution is licensed for the treatment of allergic asthma. See more here.

Basis for recommendation

The recommendations on diagnosis of asthma are based on the collaborative British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)  [BTS/NICE/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], and the BTS publication British Thoracic Society Clinical statement on occupational asthma [BTS, 2022].

Clinical features of occupational asthma

• These recommendations are based on the BTS publication [BTS, 2022], the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024], and the GINA guideline [GINA, 2024].
  • The GINA guideline notes that a diagnosis of occupational asthma or work-aggravated asthma is often missed. It is typically due to exposure to allergens or other sensitizing agents at work.
  • The collaborative BTS/NICE/SIGN guideline recommends checking for a possible occupational component in people with adult-onset asthma, poorly controlled established asthma, or reappearance of childhood asthma.

Atypical or additional symptoms and signs

Atypical or additional symptoms and signs that may suggest an alternative or coexisting diagnosis include [BTS/SIGN, 2024] [GINA, 2024]:

• In adults:
  • Predominant cough without lung function abnormalities.
  • Recurrent 'asthma exacerbations' without objective confirmatory evidence.
  • Orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema, and pre-existing cardiac disease.
  • Prominent systemic features (such as myalgia, fever, night sweats, and weight loss) and/or haemoptysis.
  • Unexpected clinical findings (such as crackles, finger clubbing, pallor, cyanosis, evidence of cardiac disease, monophonic wheeze, or stridor).
  • Age of symptom onset more than 35 years and significant smoking history (more than 30 pack-years).
  • Persistent, non-variable breathlessness or chronic productive cough.
  • Unexplained restrictive spirometry.
  • Focal or persistent chest X-ray changes.
  • Marked blood eosinophilia.
• In children:
  • Faltering growth.
  • Unexplained clinical findings (such as finger clubbing, focal chest signs, abnormal voice or cry, dysphagia, and/or inspiratory stridor).
  • Symptoms that are present from birth or a perinatal lung problem.
  • Excessive vomiting or paroxysmal coughing bouts leading to vomiting.
  • Severe upper respiratory tract disease.
  • Persistent moist cough.
  • A family history of unusual chest disease.
  • Focal or persistent chest X-ray changes.

Basis for recommendation

The recommendations on assessment are based on the collaborative British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE), and Scottish Intercollegiate Guidelines Network (SIGN) guideline Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) [BTS/NICE/SIGN, 2024], the BTS and SIGN publication British guideline on the management of asthma  [BTS/SIGN, 2024], the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], and the BTS publication British Thoracic Society Clinical statement on occupational asthma [BTS, 2022].

Clinical features on history-taking

• These recommendations are based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024], the BTS/SIGN publication [BTS/SIGN, 2024], the GINA guideline [GINA, 2024], and the BTS publication [BTS, 2022].
  • The recommendation to code as 'suspected asthma' until a diagnosis is confirmed by objective testing is based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024].
  • The GINA guideline recommends asking about the impact on daily activity and exercise, as people with poorly controlled asthma may avoid strenuous exercise, leading to poor fitness levels and an increased risk of obesity.
  • The presence of atopy increases the probability that a person with respiratory symptoms has allergic asthma, but atopy is not specific for an asthma diagnosis and it is not present in all asthma phenotypes. The presence of coexisting asthma with known food allergy is a strong risk factor for severe or life-threatening food allergy reactions [GINA, 2024].
  • The recommendation to ask about atypical or additional symptoms is based on the GINA guideline and the BTS/SIGN publication, as prompt referral for additional investigations may be needed to exclude an alternative or coexisting diagnosis.
  • The presence of comorbid conditions can contribute to symptoms and reduced quality of life, and may affect asthma control [GINA, 2024].
  • The GINA guideline notes that a diagnosis of occupational asthma is important to confirm, as a person may need to amend or change occupation with potential legal and socioeconomic implications.
  • Regarding potentially contributing environmental factors, the GINA guideline notes that there is limited evidence of clinical benefit of avoidance strategies for house dust mite and/or pets in children.
  • The GINA guideline notes that a previous history of intensive care unit admission or need for mechanical ventilation for asthma increases the future risk for asthma-related death.

Arranging immediate asthma treatment if acutely unwell at presentation

• These recommendations are based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024] and the GINA guideline [GINA, 2024].
  • The GINA guideline recommends to test before starting asthma treatment with inhaled corticosteroids (ICS) where possible, as it is often difficult to confirm the diagnosis once asthma control and symptoms improve, as lung function variability typically decreases with ICS treatment.

Arranging objective testing to confirm the diagnosis

• These recommendations are based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024] and the GINA guideline [GINA, 2024].
  • The collaborative BTS/NICE/SIGN guideline recommends to only consider diagnostic testing for asthma if the history and examination support a diagnosis of asthma.
  • The GINA guideline notes it is important to confirm the diagnosis of asthma to avoid unnecessary over- or under-treatment, and to ensure other diagnoses are not missed. It acknowledges that more than one test may be needed to confirm a diagnosis of asthma or exclude alternative causes of respiratory symptoms. The aim is to assess for evidence of excessive variability in expiratory lung function; the greater the variation in lung function or more times excess variation is seen, the more likely the diagnosis of asthma.
  • The collaborative BTS/NICE/SIGN guideline committee reviewed evidence on tests of variation in airflow obstruction and markers of allergy separately for adults and children. They noted that no test showed high enough values of both sensitivity and specificity to be diagnostic in all cases. It was agreed that a combination of tests would be needed for most people. The committee took into account the availability of tests, the ability of people to perform the tests, the acceptability, and the cost of tests when making recommendations.

Objective testing in young people and adults over 16 years

• These recommendations are largely based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024] and supported in part by the GINA guideline [GINA, 2024].
  • The collaborative BTS/NICE/SIGN guideline found that several tests showed good specificity for asthma, with values over 80% for blood eosinophils, fractional exhaled nitric oxide (FeNO, cut-off values 40–50 ppb), peak expiratory flow (PEF) variability, bronchial challenge tests, and spirometry with bronchodilator reversibility (BDR). However, sensitivity was poor for most of these, and only FeNO and bronchial challenge tests showed values over 70%. Although bronchial challenge (measuring airway responsiveness) is the most accurate test overall, it is more costly and less readily available than other tests.
  • The collaborative BTS/NICE/SIGN guideline concluded that the most cost-effective diagnostic strategy was a gradual 'rule-in' approach using less expensive and highly specific tests initially such as blood eosinophil count or a FeNO measurement which reflect atopy, and reserving bronchial challenge tests for more complex patients or those with diagnostic uncertainty.
  • The collaborative BTS/NICE/SIGN guideline recommends FeNO measurement as the initial, and possibly only, test in both adults and children. The committee agreed a 'reasonably high' cut-off value for asthma diagnosis was needed to ensure specificity with a potential reduction in sensitivity.
  • The GINA guideline cites studies that a FeNO measurement of more than 50 ppb is associated with a good short-term response to ICS, and a high FeNO result can support the decision to start ICS, but a low FeNO measurement cannot be used to decide against using ICS treatment.
  • The collaborative BTS/NICE/SIGN guideline recommends measuring spirometry with reversibility as the second step in the sequence, which is more specific than sensitive, but represents a test of airway function to complement first-line tests of blood eosinophil count or FeNO, which reflect the degree of atopy. This approach ensures that both components of asthma have potentially been assessed. If FeNO and spirometry testing are not available or there is a significant delay in obtaining them, the committee agreed it would be reasonable to use PEF variability as a substitute rule-in test.
  • CKS notes that this diagnostic approach differs from that outlined in the GINA guideline, which recommends use of spirometry first-line to assess lung function. It does not recommend the use of FeNO for ruling in or out a diagnosis of asthma, stating results are also elevated in non-asthma conditions, it is not elevated in some asthma phenotypes (including asthma with obesity), and the result may be lower in smokers and during episodes of bronchoconstriction.

Objective testing in children aged 5 to 16 years

• These recommendations are largely based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024] and supported in part by the GINA guideline [GINA, 2024].
  • The collaborative BTS/NICE/SIGN guideline committee recommends FeNO as the first-line diagnostic test as it is cheap and a highly specific rule-in test. The committee were concerned that an increasing proportion of children with asthma are non-atopic and therefore unlikely to have a raised FeNO level. These children may show BDR, and therefore spirometry with BDR was considered an appropriate and cost-effective second-line diagnostic test for children without an elevated FeNO level, or as a first-line test in children where FeNO could not be measured due to lack of availability or inability to perform the necessary expiratory manoeuvre. If spirometry is not available, the committee agreed it would be reasonable to use PEF variability as a substitute rule-in test.
  • The collaborative BTS/NICE/SIGN guideline committee found evidence that sensitisation to house dust mite on skin prick testing or an elevated total serum IgE level both showed high sensitivity for asthma diagnosis and are cost-effective next-step test options. If either test is negative, asthma can be ruled out. The overall diagnostic strategy was therefore a 'rule-in–rule-out' approach.

Objective testing in children under 5 years of age

• These recommendations are largely based on the collaborative BTS/NICE/SIGN guideline [BTS/NICE/SIGN, 2024].
  • The collaborative BTS/NICE/SIGN guideline notes that the main issue in this age-group is differentiating asthma from symptoms caused by recurrent viral infections. Asthma is more likely than recurrent viral wheeze when the episodes are frequent or severe, when they occur in the absence of other signs of viral illness, and when the child shows other evidence of atopy.
  • It noted that there was no evidence available for diagnostic tests in children under 5 years of age, and the age at which a child can co-operate with tests will vary. The committee agreed that it is usually necessary to manage these children pragmatically based on symptoms and signs only with a trial of ICS treatment. The decision to continue or stop ICS treatment or subsequently refer depends on the response to treatment, as is current clinical practice.

Basis for recommendation

The information on the differential diagnosis of asthma is based on the Global Initiative for Asthma (GINA) guideline Global strategy for asthma management and prevention [GINA, 2024], the BTS and SIGN publication British guideline on the management of asthma [BTS/SIGN, 2024], and the BTS publication British Thoracic Society Clinical statement on occupational asthma [BTS, 2022].

• The GINA guideline notes that an alternative diagnosis may co-exist with a diagnosis of asthma. It recommends that smokers or ex-smokers with asthma are assessed for chronic obstructive pulmonary disease (COPD) or overlapping features of asthma and COPD, as additional treatment may be needed.
• People with occupational asthma may have coexisting occupational rhinitis, breathing pattern disorder, inducible laryngeal obstruction, anxiety, and depression that also need assessment and treatment [BTS, 2022].

How should I manage newly diagnosed asthma and optimize treatment?

If a person has newly diagnosed or suspected asthma:

• Provide advice about sources of information and support, such as:
  • The Asthma and Lung UK website (www.asthmaandlung.org.uk) has lots of patient leaflets about Asthma and Living with a lung condition.
  • The Beat Asthma website (www.beatasthma.co.uk) has lots of resources for families and children with asthma and young people with asthma.
• Advise about self-care measures and manage any modifiable risk factors.
  • Avoid potential triggers, where possible.
  • Advise about smoking cessation, including parents and carers of children with asthma. See the CKS topic on Smoking cessation for more information.
  • Advise about weight management if the person is overweight or obese. See the CKS topic on Obesity for more information.
  • Encourage regular physical activity. If the person gets exercise-induced symptoms, advise them to take reliever medication before or during exercise.
  • Manage any comorbid conditions including emotional stress, anxiety, or depression. See the CKS topics on Generalized anxiety disorder, Depression, and Depression in children for more information.
  • Ensure the person is up-to-date with all vaccinations. See the CKS topics on Immunizations - childhood, Immunizations - pneumococcal, Immunizations - seasonal influenza for more information.
• Arrange referral to an asthma respiratory specialist if clinically indicated, for example, if there is suspected occupational asthma. See the section on Follow-up in primary care for detailed information on when to arrange specialist referral for adults and children.
• Prescribe initial treatment for newly diagnosed asthma in people aged 12 years and over:
  • Offer a low-dose inhaled corticosteroid (ICS)/long-acting beta-2 agonist (LABA) combination inhaler as an ICS/formoterol combination inhaler to be taken as needed for symptom relief (as-needed 'anti-inflammatory reliever' [AIR] therapy).
    • Consider using AIR therapy before exercise or allergen exposure if needed.
  • If the person is highly symptomatic (for example, has regular night-time waking or symptoms of a severe exacerbation), or symptoms are not controlled with as-needed AIR therapy (for example, needing to use AIR therapy 3 times a week or more), offer low-dose 'maintenance and reliever therapy' (MART) with an ICS/formoterol combination inhaler and treat any symptoms of acute exacerbation. See the section on Assessing and managing an acute exacerbation for more information.
    • Consider stepping down to as-needed AIR therapy once symptoms are controlled.
    • Be aware that only specific ICS/formoterol combination inhalers are licensed for as-needed AIR therapy and MART. See the section on ICS and ICS/LABA combination inhalers in Prescribing information for more information.
  • If low-dose MART is not controlling symptoms, offer moderate-dose MART.
  • If moderate-dose MART is not controlling symptoms despite good adherence to treatment: 
    • Measure the fractional exhaled nitric oxide (FeNO) level if available and blood eosinophil count. If either of these are raised, refer to a respiratory asthma specialist.
    • If neither the FeNO level or blood 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 for 8–12 weeks.
  • After a trial of treatment for 8–12 weeks:
    • If asthma is controlled, continue the treatment.
    • If symptom control is improved but still inadequate, continue the treatment and start a trial of the other medication (LTRA or LAMA).
    • If symptom control has not improved, stop the LTRA or LAMA and start a trial of the other medication (LTRA or LAMA).
    • If symptoms remain uncontrolled despite treatment with moderate-dose MART and trials of an LTRA and a LAMA, refer to a respiratory asthma specialist.
  • See the section on Inhaler devices for more information on prescribing inhaler devices and how to demonstrate correct inhaler technique.
  • See the BTS, NICE, and SIGN (2024) summary Algorithm C: Pharmacological management of asthma in people aged 12 years and over for more information.
  • The BTS, NICE, and SIGN (2024) document Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline provides detailed information on low, moderate, and high ICS doses for adult and paediatric maintenance therapy.
  • See the sections on ICS and ICS/LABA combination inhalers, Beta-2 agonists (SABAs and LABAs), Leukotriene receptor antagonists (LTRAs), and LAMA inhalers in Prescribing information for detailed information on doses, contraindications and cautions, adverse effects, and drug interactions.
• If people aged 12 years and over are currently using a different treatment regimen to as-needed AIR therapy or MART:
  • Change treatment for people with confirmed asthma who are currently using a short-acting beta-2 agonist (SABA) only, to a low-dose ICS/formoterol combination inhaler to be taken as needed (as-needed AIR therapy).
    • Do not prescribe a SABA to people of any age with asthma without a concomitant prescription of an ICS.
  • Consider changing treatment to low-dose MART for people with asthma that is not controlled on:
    • Regular low-dose ICS plus SABA as needed.
    • Regular low-dose ICS/LABA combination inhaler plus SABA as needed.
    • Regular low-dose ICS and supplementary therapy (LTRA) plus SABA as needed.
    • Regular low-dose ICS/LABA combination inhaler and supplementary therapy (LTRA) plus SABA as needed.
    • Note: people with an existing diagnosis of asthma who are stable on their current therapy do not have to switch treatment.
  • Consider changing treatment to moderate-dose MART for people with asthma that is not controlled on:
    • Regular moderate-dose ICS plus SABA as needed.
    • Regular moderate-dose ICS/LABA combination inhaler plus SABA as needed.
    • Regular moderate-dose ICS and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed.
    • Regular moderate-dose ICS/LABA combination inhaler and supplementary therapy (LTRA or LAMA, or both) plus SABA as needed.
  • When changing from low- or moderate-dose ICS (or ICS/LABA combination inhaler) plus supplementary therapy to MART, consider whether to stop or continue the supplementary therapy, based on the degree of benefit from this when it was first started.
  • If asthma symptoms are not controlled on high-dose ICS therapy, refer to a respiratory asthma specialist.
  • See the sections on ICS and ICS/LABA combination inhalers, Beta-2 agonists (SABAs and LABAs), Leukotriene receptor antagonists (LTRAs), and LAMA inhalers in Prescribing information for detailed information on doses, contraindications and cautions, adverse effects, and drug interactions.
• Prescribe initial treatment for newly diagnosed asthma in children aged 5–11 years:
  • Offer a twice-daily paediatric low-dose ICS, with a SABA as needed, as initial treatment. If asthma symptoms remain uncontrolled, consider one of the two following pathways, depending on the child's ability to manage a MART regimen:
    • MART regimen
      • Consider prescribing paediatric low-dose MART (off-label indication in this age-group) if the child is able to manage a MART regimen.
      • Consider increasing to paediatric moderate-dose MART (off-label indication in this age-group) if asthma symptoms are not controlled on paediatric low-dose MART.
    • Conventional regimen
      • Consider adding an LTRA to twice-daily paediatric low-dose ICS plus SABA as needed if a child has uncontrolled asthma and is unable to manage a MART regimen. Give the LTRA for a trial period of 8–12 weeks (unless there are adverse effects), then stop the LTRA if it is ineffective.
      • Offer a twice-daily paediatric low-dose ICS/LABA combination inhaler plus SABA as needed if asthma symptoms are not controlled on paediatric low-dose ICS plus SABA as needed (with or without an LTRA depending on the response to the trial of treatment).
      • Offer a twice-daily paediatric moderate-dose ICS/LABA combination inhaler plus SABA as needed if asthma symptoms are not controlled on paediatric low-dose ICS/LABA plus SABA as needed (with or without an LTRA depending on the response to the trial of treatment).
  • Refer children to a paediatric asthma specialist if asthma symptoms are not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without an LTRA, depending on the response to the trial of treatment).
  • See the BTS, NICE, and SIGN (2024) summary Algorithm D: Pharmacological management of asthma in children aged 5 to 11 years.
  • The BTS, NICE, and SIGN (2024) document Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline provides detailed information on low, moderate, and high ICS doses for paediatric maintenance therapy.
  • See the sections on ICS and ICS/LABA combination inhalers, Beta-2 agonists (SABAs and LABAs), and Leukotriene receptor antagonists (LTRAs) in Prescribing information for detailed information on doses, contraindications and cautions, adverse effects, and drug interactions.
• For children under 5 years of age with suspected or confirmed asthma, or uncontrolled asthma symptoms:
  • Consider an 8–12 week trial of twice-daily paediatric low-dose ICS as maintenance therapy (with a SABA for reliever therapy) if:
    • Symptoms at presentation indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or
    • There are severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing two or more courses of oral corticosteroids).
  • If symptoms do not resolve during the trial period, take the following sequential steps:
    • Check inhaler technique and adherence. See the section on Inhaler devices for more information.
    • Check whether there is an environmental source for symptoms (for example indoor mould exposure or cold temperatures, exposure to active or passive smoking including e-cigarettes, or exposure to high levels of air pollution).
    • Reassess for atypical or additional symptoms and signs, and whether an  alternative or coexisting diagnosis is likely. See the section on Atypical or additional symptoms and signs for more information.
    • If none of these factors explain the failure to respond to treatment, refer the child to a paediatric asthma specialist.
  • If symptoms resolve after 8–12 weeks, consider stopping the ICS and SABA treatment. Review symptoms after a further 3 months.
  • If symptoms recur by the 3-month review or there is a severe acute episode requiring oral corticosteroids or hospital admission:
    • Restart twice-daily paediatric low-dose ICS with SABA as needed as maintenance therapy, and titrate up to twice-daily paediatric moderate-dose ICS if needed (with SABA as needed) as maintenance therapy.
    • Consider a further trial without treatment after reviewing the child within 12 months.
  • If asthma symptoms are uncontrolled on twice-daily paediatric moderate-dose ICS with SABA as needed as maintenance therapy, consider a trial of an LTRA in addition for 8–12 weeks (unless there are adverse effects), then stop the LTRA if it is ineffective.
  • If a trial of an LTRA has been unsuccessful or is not tolerated, stop the LTRA and refer the child to a paediatric asthma specialist for further investigation and management.
  • See the BTS, NICE, and SIGN (2024) summary Algorithm E: Pharmacological management of asthma in children under 5 for more information.
  • The BTS, NICE, and SIGN (2024) document Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline provides detailed information on low, moderate, and high ICS doses for paediatric maintenance therapy.
  • See the sections on ICS and ICS/LABA combination inhalers, Beta-2 agonists (SABAs and LABAs), and Leukotriene receptor antagonists (LTRAs) in Prescribing information for detailed information on doses, contraindications and cautions, adverse effects, and drug interactions.
• Provide the person with a personalised asthma action plan and ensure it is reviewed at every asthma-related healthcare attendance and at annual review.
  • Base the asthma plan on symptoms (particularly for children) or PEF (or both).
  • Advise about individualized triggers for asthma symptoms and exacerbations and how to minimize exposure, where possible.
  • Advise how to recognize early signs of an asthma exacerbation, what action to take including specific instructions about changes to reliever and/or maintenance medications, and when and how to use oral prednisolone, if needed.
  • Advise what to do if symptoms do not improve, and how and when to seek urgent medical attention.
  • The Asthma and Lung UK website (www.asthmaandlung.org.uk) has information on Asthma action plans and guidance notes for HCPs, and the downloadable templates Adult asthma action plan, MART asthma action plan, and AIR asthma action plan.
  • The Beat Asthma website (www.beatasthma.co.uk) has the downloadable templates Child asthma action plan, Child MART asthma action plan, and School asthma action plan.
• Arrange to review a person with asthma in primary care after symptoms are controlled at least annually and after any asthma exacerbation. See the section Scenario: Follow-up of asthma for more information.

How should I follow-up a person with asthma?

Arrange to review a person with asthma in primary care at least annually and after any asthma exacerbation, to monitor asthma control, inhaler technique and adherence, and optimize asthma therapy.

• Observe and optimise the person's inhaler technique (and spacer if used) and adherence:
  
  • At every asthma review, either routine or unscheduled.
  • At every asthma-related consultation.
  • When there is deterioration in asthma control and when considering stepping up treatment.
  • When the inhaler device is changed.
  • When the person asks for it to be checked or changed.
• Monitor the person's asthma control by assessing symptoms and risk factors for asthma exacerbations.
  • Ask about:
    • Current day- and night-time symptoms, impact on daily activities, and any avoidable triggers.
    • Time off nursery/school/work due to asthma.
    • Adherence to asthma therapy using prescription records, including over-ordering and overuse of short-acting beta-2 agonist (SABA) inhalers (more than two inhalers per year).
    • Number of courses of oral corticosteroids (OCS, 2 or more courses in 12 months suggests poor asthma control). Ensure people needing long-term or frequent courses of OCS for acute exacerbations (three or four courses per year) are offered appropriate monitoring to reduce the risk of cumulative adverse effects. See the CKS topic on Corticosteroids - oral for more information.
    • Any medication adverse effects and treatment preferences.
    • Any hospital admissions or emergency department attendance due to asthma (two or more visits in 12 months suggests poor asthma control).
    • Exposure to smoking (active or passive) including e-cigarettes. Give smoking cessation advice if needed. See the CKS topic on Smoking cessation for more information.
    • Any occupational exposures or environmental factors that may affect asthma control.
    • Any psychosocial factors such as anxiety and/or depression, relationships, social support, and physical activity which may affect asthma control.
    • Any comorbidities such as rhinosinusitis, gastro-oesophageal reflux disease, or obesity contributing to symptoms.
    • Any symptoms suggesting an alternative diagnosis, especially if there are frequent symptoms despite good lung function.
  • Consider using a validated symptom questionnaire such as the Asthma Control Questionnaire or Asthma Control Test for adults and children over 12 years of age, or the Childhood Asthma Control Test (4–11 years) at any asthma-related review.
    • Include information from both the parent/carer and child when assessing the level of symptom control.
  • In children, monitor growth at least annually using height and weight centiles.
  • In adults, consider fractional exhaled nitric oxide (FeNO) monitoring:
    • At their regular review, and
    • Before and after changing their asthma therapy, for example if asthma is uncontrolled. If the FeNO level is raised, this may indicate poor adherence to treatment or the need for an increased dose of inhaled corticosteroid (ICS).
    • See the section Scenario: Newly-diagnosed asthma and optimizing treatment for more information on optimizing asthma treatment in different age-groups.
  • Do not use regular peak expiratory flow (PEF) monitoring to assess asthma control unless there are person-specific reasons for doing so (for example, when PEF measurement is part of the personalised asthma action plan).
    • If using PEF monitoring, the person's highest FEV₁ reading (personal best) should be documented to allow useful clinical comparisons. The best of three measurements should be used each time when monitoring, and the same peak flow meter should be used for follow-up testing.
• Consider stepping up asthma treatment if symptoms remain uncontrolled.
  • Take into account and try to address possible risk factors for uncontrolled asthma (see above) before starting or adjusting asthma medication.
  • Review the response to any treatment changes after 8–12 weeks. See the section Scenario: Newly-diagnosed asthma and optimizing treatment for more information on optimizing asthma treatment in different age-groups.
• Consider decreasing maintenance therapy once symptoms are well controlled for at least 8–12 weeks at annual review.
  • Discuss the potential risks and benefits of decreasing maintenance therapy. The aim is to prescribe the lowest dose of treatment to control symptoms and exacerbations.
  • When reducing maintenance therapy:
    • Stop or reduce the dose of medication in an order that takes into account the clinical effectiveness when introduced, any adverse effects, and the person's preference.
    • If considering step-down treatment for people aged 12 years and over who are using low-dose ICS with SABA as needed as maintenance therapy or low-dose maintenance and reliever therapy (MART), step down to low-dose ICS/formoterol combination inhaler as needed (as-needed anti-inflammatory reliever 'AIR' therapy).
    • Allow at least 8–12 weeks before considering a further treatment reduction.
    • Review and update the personalised asthma action plan accordingly.
    • Discuss how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and follow-up with a healthcare professional.
    • Seek specialist advice if there is any uncertainty about stepping down treatment, and have a lower threshold for liaising with a specialist for children with asthma.
• If a woman is pregnant, arrange an asthma review during early pregnancy and in the post-partum period.
  • Advise about the importance of maintaining good asthma control and continuing asthma medication (including SABA, long-acting beta-2 agonist [LABA], ICS, and OCS if needed).
  • Do not stop a leukotriene receptor antagonist (LTRA) or long-acting muscarinic receptor antagonist (LAMA) during pregnancy if they are needed to control asthma symptoms.
  • Advise that the benefits of treatment with OCS outweigh the risks for acute asthma exacerbations in pregnancy.
• Consider arranging referral to an asthma respiratory specialist if:
  • There is diagnostic uncertainty in children or adults.
  • An adult has suspected occupational asthma — refer to an occupational lung disease service or asthma specialist, ideally to be seen within 6 weeks of referral.
    • If occupational asthma is confirmed, advise that the best opportunity for improved asthma control comes from early, and complete, removal of exposure to the cause.
  • A person has persistent symptoms and/or exacerbations despite good adherence to optimised ICS-containing treatment for 3–6 months. See the section Scenario: Newly-diagnosed asthma and optimizing treatment for more information on optimising asthma treatment in different age-groups.
  • A person has severe asthma, difficult-to-treat asthma, or a history of near-fatal asthma exacerbation (the latter group should be under specialist supervision indefinitely).
  • A person has clinical features of both asthma and COPD, and there is uncertainty about priorities for treatment. See the CKS topic on Chronic obstructive pulmonary disease for more information.
    • In general, the person should be treated for asthma with ICS-containing treatment.
  • A child under 5 years of age is unable to perform objective tests and asthma symptoms are not responding to initial treatment.
  • A preschool child has an admission to hospital, or two or more admissions to an emergency department, with wheeze in a 12-month period — refer to a specialist respiratory paediatrician.
  • A child has a diagnosis of food allergy and/or anaphylaxis and asthma. See the CKS topics on Angio-oedema and anaphylaxis and Food allergy for more information.
  • A child has significant adverse effects from asthma treatment, such as faltering growth. See the CKS topic on Faltering growth for more information.

How should I assess and manage an acute exacerbation of asthma?

If a person has a suspected acute exacerbation of asthma, assess the severity of exacerbation and arrange prompt initiation of treatment and/or hospital admission, depending on clinical judgement.

• Examine the person to assess the severity of the exacerbation.
  • Assess vital signs — level of consciousness, temperature, pulse rate and rhythm, respiratory rate, blood pressure, oxygen saturation by pulse oximetry, ability to complete sentences, use of accessory muscles, and audible wheeze.
  • Examine the chest for signs of wheezing — wheeze may become biphasic or less apparent with increasing airway obstruction.
    • Note: people with a severe or life-threatening exacerbation may not always appear distressed, and wheezing may be absent due to severe airflow reduction ('silent chest').
  • Consider checking peak expiratory flow (PEF) — if the person is old enough and well enough. Ideally, use the best of three measurements compared with the personal best (if measured within the last 2 years) or predicted PEF value.
  • Assess for any signs of alternative conditions that could explain acute breathlessness, such as pulmonary embolism, pneumothorax, or pneumonia.
• Determine the severity of asthma exacerbation:
  • Life-threatening
    • Adults and children (suspect if any one of the following with acute severe asthma) — cyanosis, drowsy, exhaustion, poor respiratory effort, confusion (may be a sign of hypoxia); oxygen saturation on air less than 92%; hypotension; PEF less than 33% best or predicted; and/or 'silent chest'.
  • Acute severe
    • Adults (suspect if any one of the following) — inability to complete sentences in one breath; oxygen saturation on air less than 92%; respiratory rate more than 25 breaths per minute; pulse rate more than 110 beats per minute; and PEF 33–50% best or predicted.
    • Children — too breathless to talk or feed; use of accessory neck muscles; oxygen saturation on air less than 92%; PEF 33–50% best or predicted; pulse rate more than 140 beats per minute if aged 2–5 years/more than 125 beats per minute if aged more than 5 years; and respiratory rate more than 40 breaths per minutes if aged 2–5 years/more than 30 breaths per minute if aged more than 5 years.
  • Moderate
    • Adults — talking in sentences; prefers sitting to lying; not agitated; no accessory muscle use; oxygen saturation on air 92% or more; PEF more than 50% best or predicted; and no features of acute severe asthma.
    • Children — talking in sentences; oxygen saturation on air 92% or more; PEF more than 50% best or predicted; pulse rate less than 140 beats per minute if aged 2–5 years/less than 125 beats per minute if aged more than 5 years; and respiratory rate less than 40 breaths per minute if aged 2–5 years/less than 30 breaths per minute if aged more than 5 years.
• Review the person's history to help assess the severity of exacerbation and whether hospital admission is appropriate.
  • Timing of onset and cause (if known) of current exacerbation and increasing symptoms.
  • Severity of symptoms, including limiting exercise or night-time waking.
  • Any symptoms of anaphylaxis. See the CKS topic on Angio-oedema and anaphylaxis for more information.
  • Any risk factors for asthma-related death.
  • Current reliever and maintenance medications including doses and devices used, any concerns about adherence, recent dose changes, and response to therapy.
  • Attending with an exacerbation despite an adequate dose of oral corticosteroids (OCS) before presentation.
  • A history of near-fatal asthma — arrange hospital admission.
  • Any other recent or previous exacerbations, emergency department or hospital admissions for asthma.
  • Any concern about social circumstances or ability to cope at home; presentation in the evening or at night.
• If there are signs of a life-threatening exacerbation, give emergency treatment while arranging emergency transfer to hospital. Arrange emergency hospital admission if there are signs of an acute severe exacerbation not responding to initial treatment.
  • Give controlled oxygen to adults and high-flow oxygen to children (if available) aiming for an oxygen saturation of 94–98%. Note: do not delay giving oxygen if pulse oximetry is not available.
  • If there is a life-threatening exacerbation, give nebulised salbutamol (5 mg if aged over 5 years or 2.5 mg if aged 2–5 years) and nebulised ipratropium bromide (0.5 mg for adults or 0.25 mg for children aged 2–12 years) preferably via oxygen-driven nebuliser.
  • If there is an acute severe exacerbation, give nebulised salbutamol (5 mg if aged over 5 years or salbutamol 2.5 mg if aged 2–5 years) preferably via oxygen-driven nebuliser. If symptoms do not respond to initial treatment, add nebulised ipratropium bromide (0.5 mg for adults or 0.25 mg for children aged 2–12 years) preferably via oxygen-driven nebuliser.
    • Repeat doses of nebulised bronchodilator every 20–30 minutes if there is an inadequate response to initial treatment.
    • Note: if a nebuliser is not available, give salbutamol (100 micrograms) by pressurized metered-dose inhaler (pMDI) and large-volume spacer one puff every 60 seconds, according to response, up to a maximum of 10 puffs. Each puff should be given one at a time and inhaled separately using tidal breathing. Additional doses of bronchodilator should be given as needed whilst awaiting hospital transfer, for example after 10 minutes.
  • Give a first dose of oral prednisolone immediately (40 mg to 50 mg for adults and children 16 years and over; 30 mg to 40 mg for children 6–15 years; 20 mg for children aged 2–5 years; or 10 mg for children aged under 2 years).
    • If oral administration is not possible, give intramuscular (IM) methylprednisolone 160 mg to adults, or intravenous (IV) hydrocortisone 100 mg to adults and children aged 5 years and over; or IV hydrocortisone 50 mg to children aged 2–4 years.
• If there are signs of a moderate exacerbation, consider giving initial treatment in primary care and arrange urgent transfer to hospital if symptoms do not respond or are worsening at any time.
  • Give controlled oxygen to adults and high-flow oxygen to children (if available) aiming for an oxygen saturation of 94–98%. Note: do not delay giving oxygen if pulse oximetry is not available.
  • Give salbutamol (100 micrograms) by pMDI and large-volume spacer one puff every 60 seconds, according to response, up to a maximum of 10 puffs. Each puff should be given one at a time and inhaled separately using tidal breathing. Additional doses of bronchodilator should be given as needed.
    
    • If there is no clinical improvement, give salbutamol 5 mg if aged over 5 years or 2.5 mg if aged 2–5 years via nebuliser (preferably oxygen-driven).
  • Give a first dose of oral prednisolone (40 mg to 50 mg for adults and children 16 years and over; 30 mg to 40 mg for children 6–15 years; 20 mg for children aged 2–5 years; or 10 mg for children aged under 2 years).
• If there are signs of a moderate exacerbation, assess whether the person can be managed at home, if:
  • There is a good response to initial treatment and symptoms have improved.
  • PEF is improving to more than 60–80% of best or predicted.
  • Oxygen saturation on air is more than 94%.
  • The person is able to manage at home with appropriate support.
• If there are signs of a moderate exacerbation and the person can be managed at home:
  • If the person is using an ICS/formoterol combination inhaler for anti-inflammatory reliever (AIR) therapy or maintenance and reliever therapy (MART), advise to continue the usual maintenance dose, and increase reliever doses of the combination inhaler as needed (up to the maximum daily licensed dose).
    • Advise to ring 999 if the person is needing one puff of AIR or MART inhaler every 1–3 minutes up to 6 puffs, and symptoms are not controlled. Repeat after 10 minutes if symptoms are not improving.
    • See the section on ICS and ICS/LABA combination inhalers in Prescribing information for more information.
  • If an adult is using low-dose ICS maintenance treatment in a single inhaler (up to budesonide 400 micrograms equivalent), advise to consider quadrupling the regular ICS dose (up to the maximum daily licensed dose) for up to 7 days.
    • Advise to ring 999 if the person is needing a SABA by pMDI and large-volume spacer one dose every 30–60 seconds up to a maximum of 10 puffs, and symptoms are not controlled. Repeat after 10 minutes if symptoms are not improving.
    • See the section on Beta-2 agonists (SABAs and LABAs) in Prescribing information for more information.
  • Continue oral prednisolone until recovery. Dose tapering is not needed if prednisolone is prescribed for less than 2 weeks. Advise not to stop ICS while taking oral prednisolone treatment.
    • In adults and children aged 16 years and over continue for a minimum of 5 days or until recovery if longer.
    • In children aged 6–15 years, continue for a minimum of 3–5 days or until recovery if longer.
    • In children aged 2–5 years, continue for a minimum of 3–5 days or until recovery if longer.
    • See the CKS topic on Corticosteroids - oral for more prescribing information on contraindications and cautions, adverse effects, and drug interactions.
  • Do not routinely prescribe antibiotics for asthma exacerbations.
  • Check inhaler technique and adherence. See the section on Inhaler devices for more information.
  • Arrange to review the person within 2 working days.
• When reviewing the person within 2 working days of an acute exacerbation:
  • Reassess the person's symptoms and signs to check if the exacerbation is resolving.
  • Assess whether the person needs additional short-term oral prednisolone treatment until full recovery.
  • Assess for and manage any modifiable risk factors and triggers for exacerbations, including inhaler technique and adherence. See the section on Inhaler devices for more information.
  • Review and update the person's personalised asthma action plan.
    • Consider prescribing a short course of oral prednisolone as rescue medication for the person to keep at home, depending on clinical judgement. Update the asthma action plan to clarify when to start treatment during early signs of an exacerbation, and to contact a primary healthcare professional as soon as treatment is started, if symptoms worsen, and/or if symptoms do not improve before the end of the course.
  • Ensure the person attends for regular follow-up in primary care. See the section Scenario: Follow-up of asthma for more information.

Doses and devices

Inhaled corticosteroids (ICS) used in the treatment of asthma include beclometasone, budesonide, ciclesonide, fluticasone, and mometasone [BTS/NICE/SIGN, 2024].

• A variety of combination ICS/long-acting beta-2 agonist (LABA) inhalers containing an ICS and the LABA formoterol are licensed for use as anti-inflammatory reliever (AIR) therapy and maintenance and reliever therapy (MART) in the UK.
  
  • A dry powder inhaler (DPI) may be used, but other device options may be considered. Not all products have UK marketing authorisation for use at all dosages or for all ages [BTS/NICE/SIGN, 2024].
  • ICS/LABA combination inhalers containing a non-formoterol LABA (such as salmeterol) are not licensed for AIR or MART due to their slower onset of action compared with formoterol [BTS/NICE/SIGN, 2024].
  • The Right Breathe website (www.rightbreathe.com) provides information on different ICS/formoterol inhalers which are licensed for adults, young people, and children with asthma.
  • The British National Formulary (BNF) provides information on which inhalers are licensed for AIR and MART, and the maximum licensed doses for each medication and device.
• The BTS/NICE/SIGN document Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline provides tables with detailed information on low, moderate, and high ICS doses which are used for adult and paediatric regular maintenance therapy.
  • The doses relate to the metered ICS dose in either an ICS inhaler or a combination ICS/LABA inhaler.
  • The doses are not strict dose equivalences but are a guide to similar clinical effectiveness.
  • Clinical judgement should be used for doses in children and young people, taking into account the severity of symptoms and the child or young person's relative size.
  • The smallest ICS dose should be used to obtain optimal asthma control, to reduce the risk of adverse effects.
  • Inhaled corticosteroids (ICS) can be given via a pressurized metered dose inhaler (PMDI) or a dry powder inhaler (DPI). See the section on Inhaler devices for more information.
• Some combination ICS/LABA inhalers are not currently licensed for use as MART for children under the age of 12 years.
  • The BTS/NICE/SIGN document states that a paediatric MART regime may be considered if a child is able to manage this, but prescribing an ICS/LABA for MART is an off-label indication with some inlahers in this age-group [BTS/NICE/SIGN, 2024]. See the section on Newly-diagnosed asthma and optimising treatment for more information.
• See the CKS topic on Corticosteroids - inhaled for detailed information about the contraindications and cautions, adverse effects, and drug interactions of ICS, and when to issue a steroid treatment card.
• See the section on Beta-2 agonists (SABAs and LABAs) in Prescribing information for more information about the contraindications and cautions, adverse effects, and drug interactions of the LABA constituent of ICS/LABA combination inhalers.

Dose

Montelukast is an oral leukotriene receptor antagonist (LTRA). There are no listed contraindications or cautions in the British National Formulary (BNF).

• Montelukast
  • 10 mg once daily in the evening in adults and young people aged 15 years and older.
  • 5 mg once daily in the evening in children aged 6–14 years.
  • 4 mg once daily in the evening in children aged 6 months to 5 years.

 [BNF, 2024] 

Adverse effects

• Possible adverse effects of montelukast include:
  • Diarrhoea, fever, gastrointestinal discomfort, headache, nausea, skin reactions, upper respiratory tract infection, and vomiting (common or very common).
  • Akathisia, anxiety, arthralgia, asthenia, behaviour abnormal, depression, dizziness, drowsiness, dry mouth, haemorrhage, malaise, mood altered, muscle complaints, oedema, seizure, sensation abnormal, and and sleep disorders (uncommon).
  • Angioedema, concentration impaired, disorientation, eosinophilic granulomatosis with polyangiitis, erythema nodosum, hallucination, hepatic disorders, memory impairment, palpitations, psychiatric disorders, pulmonary eosinophilia, speech disorder, suicidal behaviours, and tremor (rare or very rare).
• Advise about the risk of neuropsychiatric reactions including new or worsening changes in mood, sleep, or behaviour (such as nightmares, aggression, anxiety, depression, or thoughts of self-injury). Advise the person to stop montelukast and seek immediate medical attention if suspected.

[BNF, 2024] 

Drug interactions

Possible drug interactions with montelukast include:

• Carbamazepine — is predicted to decrease the exposure to montelukast
• Clopidogrel — is predicted to moderately increase the exposure to montelukast.
• Leflunomide — is predicted to increase the exposure to montelukast. Manufacturer makes no recommendation.
• Phenobarbital — is predicted to decrease the exposure to montelukast. Manufacturer advises caution.
• Phenytoin — is predicted to decrease the exposure to montelukast. Manufacturer advises caution.
• Primidone — is predicted to decrease the exposure to montelukast. Manufacturer advises caution.
• Rifampicin — is predicted to decrease the exposure to montelukast. Manufacturer advises caution.

[BNF, 2024] 

Dose

Long-acting muscarinic receptor antagonist (LAMA) inhalers such as tiotropium may be used as add-on therapy in the management of asthma.

• Tiotropium (as Spiriva Respimat^®) in people aged 12 years and over — 5 micrograms once daily.

[BNF, 2024] 

Contraindications and cautions

• Prescribe long-acting muscarinic receptor antagonist (LAMA) inhalers with caution to people with:
  • Bladder outflow obstruction.
  • Paradoxical bronchospasm.
  • Prostatic hyperplasia.
  • Susceptibility to angle-closure glaucoma.
• Prescribe tiotropium with caution to people with:
  • Arrhythmia (unstable, life-threatening, or requiring intervention in the previous 12 months).
  • Heart failure (hospitalisation for moderate to severe heart failure in the previous 12 months).
  • Myocardial infarction in the previous 6 months.

[BNF, 2024] 

Adverse effects

Possible adverse effects of long-acting muscarinic receptor antagonist (LAMA) inhalers include:

• For all inhaled LAMAs:
  • Arrhythmias, constipation, cough, dizziness, dry mouth, headache, and nausea (common or very common).
  • Dysphonia, glaucoma, palpitations, skin reactions, stomatitis, urinary disorders, and vision blurred (uncommon).
• For tiotropium:
  • Gastrointestinal disorders, increased risk of infection, and taste altered (uncommon).
  • Bronchospasm, dysphagia, epistaxis, insomnia, and oral disorders (rare or very rare).

[BNF, 2024] 

Drug interactions

Possible drug interactions with the long-acting muscarinic receptor antagonist (LAMA) inhalers include:

• Clozapine — both LAMAs and clozapine can cause constipation. Concurrent use might increase the risk of developing intestinal obstruction. Manufacturer advises caution.
• Levodopa — both LAMAs might decrease the absorption of levodopa. Manufacturer makes no recommendation.
• Other antimuscarinic drugs — concomitant use with a LAMA is not recommended as both can cause antimuscarinic effects.

[BNF, 2024] 

Dose

• Short-acting beta-2 agonists (SABAs) such as salbutamol and terbutaline have a rapid onset of action (5 minutes) and their effects last for up to 4 hours.
  • Do not prescribe a SABA to people of any age with asthma without a concomitant prescription of an inhaled corticosteroid (ICS). See the section on  ICS and ICS/LABA combination inhalers in Prescribing information for more information.
  • See the sections on Newly-diagnosed asthma and optimising treatment and Assessing and managing an acute exacerbation for more information on SABA as-needed reliever doses for the management of asthma including acute exacerbations.
• A variety of combination ICS/long-acting beta-2 agonist (LABA) inhalers containing an ICS and the LABA formoterol are licensed for use as an anti-inflammatory reliever (AIR) therapy and maintenance and reliever therapy (MART) in the UK, such as Symbicort^®, Fostair^®, DuoResp^®, Fobumix^®, Luforbec^®, and Wockair^®.
  • Not all products have UK marketing authorisation for use at all dosages or for all ages [BTS/NICE/SIGN, 2024].
  • Do not prescribe an LABA to people of any age with asthma without a concomitant prescription of an ICS [BTS/NICE/SIGN, 2024].
  • See the section on Newly-diagnosed asthma and optimising treatment for more information on ICS/formoterol combination inhaler doses recommended for AIR therapy and when to step up treatment.
  • See the section on ICS and ICS/LABA combination inhalers in Prescribing information for more information on ICS/formoterol combination inhaler doses that are used for adult and paediatric regular maintenance therapy.

Contraindications and cautions

• Beta-2 agonists should be used with caution in people with:
  • Hyperthyroidism — beta-2 agonists may stimulate thyroid activity.
  • Diabetes mellitus — risk of hyperglycaemia and ketoacidosis.
  • Arrhythmias; cardiovascular disease; hypertension — beta-2 agonists may cause an increased risk of arrhythmias and significant changes to blood pressure and heart rate.
  • Susceptibility to QT interval prolongation.
  • Hypokalaemia — plasma potassium concentration may be reduced (particularly with high doses).

[BNF, 2024] 

Adverse effects

• Possible adverse effects of inhaled beta-2 agonists are usually dose-related and include:
  • Arrhythmias, headache, muscle spasms, nasopharyngitis, oropharyngeal pain, palpitations, rash, and tremor (common or very common).
  • Hyperglycaemia (uncommon).
  • Paradoxical bronchospasm (very rare).

[BNF, 2024] 

Drug interactions

Possible drug interactions associated with inhaled beta-2 agonists include:

• Aminophylline and theophylline — concomitant administration with aminophylline can increase the risk of hypokalaemia.
• Amiodarone, amisulpride, aripiprazole, citalopram, erythromycin, fluconazole, haloperidol, moxifloxacin, ondansetron, quinine, sotalol, and tolterodine — concomitant administration is predicted to cause hypokalaemia (potentially increasing the risk of torsade de pointes) when given with these drugs. The manufacturer makes no recommendation.
• Corticosteroids — concomitant administration can increase the risk of hypokalaemia.
• Diuretics such as bendroflumethiazide, bumetanide, furosemide, indapamide, and metolazone — concomitant administration can increase the risk of hypokalaemia.
• Digoxin — concomitant administration is predicted to increase the risk of digoxin toxicity. The manufacturer advises caution.
• Ipratropium — concomitant administration is predicted to increase the risk of glaucoma when given with ipratropium. The manufacturer makes no recommendation.
• Selegiline — concomitant administration with selegiline is predicted to increase the risk of severe hypertension. The manufacturer advises avoiding.

[BNF, 2024]