Management of Asthma in Adults

Use the least expensive product that is suitable for the individual patient, within its marketing authorisation

Before starting a new therapy practitioners should check concordance and inhaler technique with existing therapy

Patients should start treatment at the step most appropriate to the initial severity of asthma symptoms
following reconsideration and review of the diagnosis

Step up to improve control and step down to find and maintain lowest controlling step

Step 1: Mild intermittent asthma	Step 2: Regular preventer therapy	Step 3: Initial add-on therapy	Step 4: Persistent poor control	Step 5: Continuous or frequent use of oral steroids
Inhaled short acting B₂-agonist Prescribe inhalers only after the patient has received training in the use of the device and has demonstrated satisfactory technique	Add inhaled corticosteroid (ICS) 200-800mcg/day (BDP or equivalent) Start dose of inhaled corticosteroid appropriate to severity of disease. 400mcg/day (BDP or equivalent) is an appropriate dose for most patients	1. Add inhaled long-acting B₂-agonist (LABA) and assess control of asthma: Good response to LABA Continue LABA Combination inhalers should be considered in those for whom LABA are effective at controlling symptoms. Benefit from LABA but control still inadequate Continue LABA and increase inhaled steroid dose to 800 mcg/day BDP or equivalent (if not already on this dose) No response to LABA Stop LABA and increase inhaled steroid to 800mcg/ day. BDP or equivalent 2. If control still inadequate, Institute trial of other therapies, leukotriene antagonist or SR theophylline receptor	Consider trials of: Increased dose of inhaled corticosteroid up to 2000mcg/day (BDP or equivalent) Consider adding a fourth drug eg leukotriene receptor antagonist, SR theophylline or B₂-agonist tablet	Use daily steroid tablet in lowest dose to provide adequate control Maintain high dose inhaled corticosteroids at 2000mcg/day (BDP or equivalent) Consider other treatments to minimise the use of oral steroids Refer patient for specialist care
In selected patients at Step 3 who are poorly controlled, or in selected patients at step 2 who are poorly controlled, the use of budesonide/formoterol in a single inhaler as rescue medication and maintenance therapy can be an effective treatment option. For more information on combination inhalers click on Combination inhalers and Combination of budesonide/formoterol in a single inhaler.
Regular review of patients as treatment is stepped down is important. Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Any reduction in inhaled steroids should be undertaken slowly, every three months, as patients deteriorate at different rates. Inhaled corticosteroid reduction in severe asthma should be reduced by 25% only, 50% for more stable patients