• 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). Use half the 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 year 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.
• 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.

In depth

• Review a person with stable asthma at least once a year. More frequent follow up may be needed after the initial diagnosis, when there is a change to medication, or in people with severe asthma or recurrent exacerbations.
• Review asthma control:
• Ask about symptoms during the day; difficulty sleeping; and the impact of asthma on such activities as exercise, work, school and psychological wellbeing in the past week or month.
• Ask about past exacerbations and their frequency, and whether oral corticosteroids or hospital admission was needed.
• Ask about possible trigger factors such as exercise, work, and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis, sleep apnoea, and gastro-oesophageal reflux disease.
• Look for signs of complications which may necessitate referral to a specialist.
• Review asthma medication:
• Ask about the use of reliever medication, any benefits seen with changes in medication, and compliance with treatment.
• Assess the person's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage people with asthma or parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.