• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the parents 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 children, for rapid symptom relief.
• Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose that is appropriate for the severity of symptoms (usually equivalent to beclometasone CFC-free as Clenil Modulite^® 200 to 400 micrograms/day). Indications for ICS include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night weekly or more, or
• Having an exacerbation in the last 2 years, or
• Using inhaled short-acting beta₂-agonist three times weekly or more.
• If ICS are not tolerated or are contraindicated, consider starting a leukotriene receptor antagonist at step 2 (but do so only in children aged 2–5 years).
• Step 3: If the child still has symptoms while using regular ICS (equivalent to Clenil Modulite^® [beclometasone CFC-free] 400 micrograms/day), consider:
• For children younger than 2 years: move to step 4.
• For children aged 2–5 years: initiate a trial of a leukotriene receptor antagonist; if asthma remains inadequately controlled, move to step 4.
• Step 4: Refer to a paediatrician with knowledge about respiratory diseases.
• Offer self-management education, including written action plans focusing on the child's and the family's needs.

In depth

• Review a child 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 children 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 and schooling 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 and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis.
• 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 child's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

• Adjust treatment using the step-wise approach outlined below.
• Before starting a new drug or stepping up treatment, confirm with the parents 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 children 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 400 micrograms/day. Indications include:
• Having symptoms three times weekly or more, or
• Awakening with symptoms one night a week or more, or
• Having an exacerbation in the past 2 years, or
• Using their inhaled beta₂-agonist three times weekly or more.
• If ICS therapy is not tolerated, consider starting a leukotriene receptor antagonist or cromones. 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 Long-acting beta2-agonists (LABA) if symptoms are still uncontrolled when using an ICS at 400 micrograms/day:
• If the child has a good response to the LABA with adequate symptom control, continue the LABA and current dose of the ICS.
• If the child has a good response to the LABA but symptom control is still inadequate, and the child is receiving 400 micrograms/day of an ICS, continue the LABA and go to step 4.
• If the child does not respond to LABA, stop the LABA. If the symptom control is inadequate and the child is receiving 400 micrograms/day of an ICS, then consider an alternative add-on treatment, such as a leukotriene receptor antagonist or modified-release theophylline, before moving to step 4.
• Step 4: Consider increasing the ICS to the maximum recommended daily dose. For beclometasone CFC-free as Clenil Modulite^® this is 800 micrograms/day.
• Step 5: Refer to a paediatrician with knowledge of respiratory medicine.
• Offer self-management education, including written action plans focusing on the individual's needs.

In depth

• Review a child 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 children 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 and schooling 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 and allergens.
• Ask about other conditions, that are known to co-exist with asthma and aggravate symptoms: for example, allergic rhinitis.
• 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 child's inhaler technique and check peak expiratory flow rate to compare with the previously recorded value.
• Review smoking habit. Encourage parents of children with asthma to stop smoking.
• Review self-management education and make any necessary changes to written action plans.

• 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.

• Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique.
• When choosing an inhaler device for a person with asthma, consider:
• The availability of the drug and dose in the specific device
• The ability of the person to develop and maintain an effective technique with the specific device
• The suitability of the device to the person's (and carer's) lifestyles
• The person's preference for and willingness to use a particular device
• Cost
• For adults:
• A pressurized metered-dose inhaler (pMDI) with or without a spacer is generally recommended for delivery of inhaled corticosteroids and bronchodilators.
• A dry-powder inhaler (DPI) or a breath-actuated MDI is recommended for people who are unable or unwilling to use a standard pMDI and spacer.
• For children aged 5 to 15 years:
• For inhaled corticosteroids, a pMDI with a suitable spacer device is recommended. If the child is unable or unwilling to use a standard pMDI and spacer, consider a DPI or a breath-actuated MDI.
• For bronchodilators, consider a wider range of devices (e.g. DPI, breath-actuated MDI), taking into account the need for portability (for symptomatic relief when needed).
• For children younger than 5 years:
• A pMDI with a suitable spacer device, with a face mask where necessary, is recommended for the delivery of inhaled corticosteroid and bronchodilators.

For more information on delivery devices see Choice of inhaled delivery system.

• Use the lowest dose of inhaled corticosteroid (ICS) that maintains effective control of asthma.
• Prescribe CFC-free beclometasone inhalers by brand name (Clenil Modulite^® or Qvar^®); they are not equivalent and must not be interchanged.
• To reduce the risk of oral candidiasis, especially with high doses of ICS:
• Recommend a large-volume spacer device for people using a pMDI.
• Advise people to rinse their mouth with water (or clean children's teeth) after inhalation of a dose of ICS.
• In people using high doses of ICS for prolonged periods, advise on general measures to counteract osteoporosis (such as regular exercise, smoking cessation, and adequate calcium intake).
• In all children receiving prolonged treatment with ICS measure height regularly and record on a growth chart. If there is any slowing of growth reduce the dose if possible and/or refer to a specialist.
• For children treated with 800 micrograms or more of beclometasone or equivalent daily, provide specific written advice about steroid replacement in the event of a severe intercurrent illness. Consider use of a steroid warning card. Note: any child receiving this dose should be under the care of a specialist paediatrician.
• Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with shock or decreased consciousness:
• Check serum biochemistry and blood glucose levels urgently.
• Consider whether intramuscular hydrocortisone is required.
• Advise parents to immediately report non-specific symptoms, such as anorexia, abdominal pain, weight loss, tiredness, headache, nausea, vomiting, decreased consciousness, hypoglycaemia, and seizures, in children using ICS.

For full details see Prescribing information.

• Do not prescribe a long-acting beta₂ agonist (LABAs) for someone who is not already using an ICS.
• Do not stop inhaled corticosteroid treatment whilst an individual is using a LABA.
• Do not start anyone with acutely deteriorating asthma on LABA therapy.
• Closely monitor anyone started on an LABA, especially during the first 3 months of treatment.
• Only continue therapy with LABAs if they have shown benefit.
• Advise people who have been prescribed salmeterol that they should not use it to relieve an acute asthma attack.

For full details see Prescribing information.

• When prescribing theophylline, the brand should be specified on the prescription.
• Serum levels of theophylline are increased in people with heart failure or hepatic impairment, in elderly people, and by drugs that inhibit hepatic enzymes (e.g. cimetidine, ciprofloxacin, erythromycin):
• If people whose disease is stable during theophylline therapy begin to take one of these drugs, consider reducing the dose of theophylline.
• Serum levels of theophylline are decreased in people who smoke, in chronic alcoholism, and by drugs that induce hepatic enzymes (e.g. phenytoin, carbamazepine, rifampicin):
• If people whose disease is stable during theophylline therapy begin to take one of those drugs, consider increasing the dose of theophylline.
• If people whose disease is stable during theophylline therapy stop smoking, a reduction in dose may be necessary.
• Once a maintenance dose has been reached, check serum theophylline concentration every 6 to 12 months, or if the person is experiencing adverse effects that might suggest toxicity (e.g. nausea, vomiting, tremor, palpitations, or arrhythmias).

For full details see Prescribing information.

• Zafirlukast: if clinical symptoms or signs suggestive of liver dysfunction occur (e.g. anorexia, nausea, vomiting, right upper quadrant pain, fatigue, lethargy, flu-like symptoms, enlarged liver, pruritus, or jaundice), stop zafirlukast and immediately measure serum transaminases, (in particular, serum alanine aminotransferase). Routine monitoring of liver function is not recommended.
• Use in children: montelukast is the only leukotriene receptor antagonist licensed for use in children (aged 6 months and older).
• Use in pregnancy: do not start a leukotriene receptor antagonist during pregnancy. However, if a woman is already taking a leukotriene receptor antagonist and it is considered essential, treatment can be continued during pregnancy.

For full details see Prescribing information.

• Advise people that inhaled sodium cromoglicate or nedocromil sodium should be used regularly, usually four times a day.
• Cromone inhalers should not be used to relieve an acute attack of asthma.
• If inhalation of the dry powder form of sodium cromoglicate causes bronchospasm, advise the person to use their short-acting btea₂ agonist inhaler (salbutamol or terbutaline) a few minutes prior to using the sodium cromoglicate inhaler.

For full details see Prescribing information.

• Adverse effects are uncommon with infrequent, short courses of oral corticosteroids.
• After recovery from an acute exacerbation, prednisolone can be stopped abruptly, without tapering the dose, unless the course was longer than 3 weeks or the person was previously receiving maintenance oral corticosteroid treatment.

For full details see Prescribing information.

• The decision to refer is influenced by local referral pathways, the individual, and the experience of the primary healthcare provider.
• In addition to respiratory physicians and paediatricians with a specialist interest in respiratory medicine, such specialists as dietitians, physiotherapists, occupational therapists, and respiratory nurse specialists may be involved in the management of asthma at any stage.
• Admit or refer adults for specialist assessment or further investigation in the following situations:
• The diagnosis is unclear or in doubt:
• Unexpected clinical findings (e.g. crackles, clubbing, cyanosis, cardiac disease).
• Persistent non-variable breathlessness.
• Monophonic, unilateral or fixed wheeze or stridor.
• Persistent chest pain or atypical features.
• Prominent systemic features e.g. weight loss, myalgia, fever.
• Persistent cough or sputum production.
• Spirometric or peak expiratory flow measurements that do not fit the clinical picture e.g. unexplained restrictive spirometry.
• Suspected occupational asthma.
• Non-resolving pneumonia.
• Inadequate response to maximum guideline treatment.
• Admit or refer children for specialist assessment or further investigation in the following situations:
• The diagnosis is unclear or in doubt (the younger the child, the more difficult it is to be sure that wheezing is due to asthma):
• Unexpected clinical findings (e.g. abnormal voice, focal chest signs, dysphagia, inspiratory wheeze, stridor).
• Symptoms present from birth, or perinatal lung problem.
• Excessive vomiting or posseting.
• Severe upper respiratory tract infection.
• Persistent productive cough.
• Family history of unusual chest disease.
• Failure to thrive.
• Parental anxiety.
• Inadequate response to maximum guideline treatment, particularly if oral corticosteroids are needed frequently, or use of the maximum dose of inhaled corticosteroids.

In depth

• Advise overweight people that a healthy diet and regular exercise will help with weight reduction and improve asthma control:
• Advise people (if possible) to take 30 minutes of exercise to increase their heart rate at least five times weekly. For more information on weight loss, see the CKS topic on Obesity.

In depth

• Advise smokers with asthma to stop smoking and provide them with the appropriate help. For more information, see the CKS topic on Smoking cessation.
• Advise people with asthma to, as far as possible, avoid exposure to tobacco smoke. For parents who smoke and have a child with asthma, this means either stopping smoking (the best option), or not smoking in the same room as the child (or, preferably, not smoking in the house).

In depth

• Advise an influenza and a pneumococcal vaccination if asthma is severe and requires hospital admission or frequent use of corticosteroids.
• For more information, see the CKS topics on:
• Immunizations - seasonal influenza.
• Immunizations - pneumococcal.

In depth

• Advise to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.

In depth

• Advise to avoid (if possible) known trigger factors, especially at times when asthma is poorly controlled.
• Advise all adults to report promptly any worsening asthma control during work.

In depth