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Asthma - Management
People over 12 years of age with uncontrolled symptoms on current treatment: How do I manage?

  • Adjust treatment using the step-wise approach outlined below.
  • Before starting a new drug or stepping up treatment, confirm with the person their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
  • Choose an effective delivery system on the basis of convenience, cost, and suitability:
    • Step 1: Prescribe a short-acting beta2-agonist to all people with asthma, for rapid symptom relief.
    • Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose most appropriate to the severity of symptoms (for beclometasone-CFC free as Clenil Modulite®, this is 200 to 800 micrograms/day, with 400 micrograms/day being appropriate for most people older than 12 years of age). Use half the equivalent dose for Qvar®. Indications include:
      • Having symptoms three times weekly or more, or
      • Awakening with symptoms one night weekly or more, or
      • Having an exacerbation in the past 2 years, or
      • Using inhaled beta2-agonist three times weekly or more.
    • If ICS are not tolerated, consider starting a leukotriene receptor antagonist or cromone. Long-acting beta2-agonists (LABA) should only be prescribed with an ICS and therefore should not be considered an alternative to ICS.
    • Step 3: Consider starting a long-acting beta2-agonist (LABA) if symptoms are still uncontrolled with the ICS (irrespective of the dose used):
      • If the person has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
      • If the person has a good response to the LABA but control remains inadequate, continue the LABA, but increase ICS up to 800 micrograms/day (half the dose for Qvar®). If the person is receiving 800 micrograms/day and control remains poor, move to step 4.
      • If the person does not respond to LABA, stop LABA therapy and increase ICS up to 800 micrograms/day (unless the person is already receiving this dosage). If control remains poor, consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
      • The Symbicort SMART ® regimen (a budesonide/formoterol combination inhaler used as a preventer and reliever) is an alternative in selected adults (18 years of age and older) who respond to a LABA but are poorly controlled, or in adults who are taking an ICS alone (above 400 micrograms/day) but are poorly controlled. The regular maintenance dose of budesonide should not be decreased, and may be budesonide 200 or 400 micrograms twice a day, depending on symptom severity. If the person regularly uses Symbicort® as a reliever once a day or more, review treatment.
      • People using the Symbicort SMART® regimen should be advised to continue using the inhaler regularly twice a day, as well as when required. Careful explanation is needed about why Symbicort® can be used as a reliever as well as a preventer, and why it is important to arrange a review if Symbicort® regularly needs to be used as a reliever (to review control of asthma and the risk of dose-related adverse effects).
    • Step 4: If control is still inadequate, either increase ICS to the maximum dose (for beclometasone CFC-free as Clenil Modulite®, this is 2000 micrograms/day) or consider starting a fourth drug that the person is not already using, such as a leukotriene receptor antagonist, modified-release theophylline, or an oral modified-release beta2-agonist.
      • Symbicort SMART® is not suitable (or licensed) for use in people who require more than 800 micrograms/day of budesonide for prevention.
    • Step 5: Refer to a specialist in respiratory medicine. Consider stopping any add-on therapy (or reducing the ICS dose) if these options are ineffective, whilst referring to a specialist.
  • Offer self-management education, including written action plans focusing on the individual's needs.
Clarification / Additional information
  • The duration of a trial of add-on therapy depends on the desired outcome. A trial of days to weeks may suffice for symptom relief, whilst it may take weeks to months for benefit to be seen in exacerbation rates. For most preventive therapies, improvements begin within days, but the full benefit may only be evident after 3 or 4 months, especially in severe and chronically undertreated disease [GINA, 2006].
  • Short-acting beta2-agonists may be needed on a regular basis to provide temporary relief of uncontrolled symptoms. The aim is to stop the need for reliever medication by using adequate preventive therapy.
  • Inhaled corticosteroids are usually prescribed at the lowest dose needed to achieve control and are rarely not tolerated.
  • Inhaled long-acting beta2-agonists (LABA): when starting therapy with LABA, it may be more practical to prescribe separate LABA and ICS inhalers to allow titration of doses.
  • Leukotriene receptor antagonists may be preferred to modified-release theophylline or oral modified-release beta2-agonist because they are associated with fewer adverse effects. In practice modified-release theophylline and oral modified-release beta2-agonists are not routinely prescribed in primary care.
  • Oral corticosteroids are an option for people whose asthma remains inadequately controlled after step 4, but they should not be prescribed without specialist advice.
Basis for recommendation
  • These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
    • For steps 2, 3, and 4, the benefits of treatment in trials are based on improvements in symptoms and lung function, reduced exacerbations and a good safety profile. The British Thoracic Society based their add-on regimens on extrapolated evidence from trials of add-on therapy to ICS and on previous guidelines. Few clinical trials are available in specific patient groups to guide specific management.
    • Inhaled corticosteroids (ICS): The evidence suggests that ICS are the most effective preventive treatment for all people with asthma. Nevertheless, there are concerns about local and systemic adverse effects when ICS are used in high doses.
    • Long-acting beta2-agonists (LABA): The evidence suggests that adding a LABA controls asthma better than increasing the ICS dose. Use of LABA alone (without ICS) appears to be associated with an increased risk of asthma-related death.
    • Leukotriene receptor antagonists: The evidence suggests that these agents improve asthma symptoms and lung function when added to ICS; however, they do not provide any greater benefit than increasing ICS alone.
    • Theophylline: The evidence suggests that increasing the ICS dose provides better asthma control than adding in theophylline. Comparison studies with other add-on therapy are limited, but theophylline appears to have a worse adverse effect profile than other drugs used.
    • Cromones: Limited and inconclusive evidence suggest that cromones may provide some benefit in controlling asthma symptoms.
    • Always refer people to a specialist before starting therapy with oral corticosteroids, as they require close monitoring for such adverse effects as hypertension, diabetes, reduced growth (in children), and cataracts.
    • Combination inhalers: evidence indicates that using the combination inhaler Symbicort® (budesonide and formoterol) as a maintenance and reliever therapy (Symbicort SMART®) may be similarly effective to conventional methods at reducing exacerbation rates in people with moderate to severe asthma.

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