page192
Management
o f
ch r o n ic a s t h m a
Important
Start
at
step most
appropriate to initial
severity;
before initiating a new drug consider whether
diagnosis is correct, check compliance and inhaler technique, and eliminate trigger factors for acute exacerbations
A d u l t
a n d C h i l d o v e r
5 y e a r s
Step 1: occasional relief bronchodilator
Inhaled short-acting beta
2
agonist as required (up to once
daily)
Note
Move to step 2 if needed more than twice a week,
or if
night-time symptoms more than once a week, or if exacerbation
in the last 2 years
Step 2: regular inhaled preventer therapy
Inhaled short-acting beta
2
agonist as required
plus
Regular standard-dose
1
inhaled corticosteroid (alter-
natives
2
are considerably less effective)
Step 3: inhaled corticosteroid + long-acting inhaled
beta
2
agonist
Inhaled short-acting beta
2
agonist as required
plus
Regular standard-dose
1
inhaled corticosteroid
plus
Regular inhaled long-acting beta
2
agonist (salmeterol
or
formoterol)
If asthma not controlled
Increase dose of inhaled corticosteroid to upper end of
standard dose range
1
and
Either stop long-acting beta
2
agonist if of no benefit
Or continue long-acting beta
2
agonist if of some benefit
If asthma still not controlled and long-acting beta
2
agonist
stopped, add one of
Leukotriene receptor antagonist
Modified-release oral theophylline
Modified-release oral
beta
2
agonist;
CHILD
under 12
years not recommended
Step 4: high-dose inhaled corticosteroid + regular
bronchodilators
Inhaled short-acting beta
2
agonist as required
with
Regular high-dose
3
inhaled corticosteroid
plus
Inhaled long-acting beta
2
agonist
plus
In adults 6-week sequential therapeutic trial of one or more
of
Leukotriene receptor antagonist
Modified-release oral theophylline
Modified-release oral beta
2
agonist
Step 5: regular corticosteroid tablets
Refer to a respiratory specialist
Inhaled short-acting beta
2
agonist as required
with
Regular high-dose
3
inhaled corticosteroid
and
One or more long-acting bronchodilators (see step 4)
plus
Regular prednisolone tablets (as single daily dose)
Note
In addition to regular prednisolone,
continue high-dose
inhaled corticosteroid (in exceptional cases may exceed
licensed doses); these patients should normally be referred to an
asthma clinic
Stepping down
Review treatment every 3 months;
if control achieved,
stepwise reduction may be possible; reduce dose of
inhaled
corticosteroid slowly (consider reduction every 3 months,
decreasing dose by up to 50% each time)
C h i l d u n d e r
5 y e a r s
4
Step 1: occasional relief bronchodilator
Short-acting beta
2
agonist as required (not more than once
daily)
Note
Preferably by inhalation (less effective and more side-
effects when given by mouth)
Move to step 2 if needed more than twice a week, or if night-
time symptoms more than once a week, or if exacerbation in the
last 2 years
Step 2: regular preventer therapy
Inhaled short-acting beta
2
agonist as required
plus
Either regular standard-dose
1
inhaled corticosteroid
Or (if inhaled corticosteroid cannot be used) leukotriene
receptor antagonist
Step 3: add-on therapy
Child under 2 years:
Refer to respiratory paediatrician
Child 2–5 years:
Inhaled short-acting beta
2
agonist as required
plus
Regular inhaled corticosteroid in standard dose
1
plus
Leukotriene receptor antagonist
Step 4: persistent poor control
Refer to respiratory paediatrician
Stepping down
Regularly review need for treatment
1.
Standard-dose inhaled corticosteroids
Beclometasone
dipropionate
or
budesonide
100–
400 micrograms twice daily;
CHILD under 12 years 100–
200 micrograms twice daily
Fluticasone propionate 50–200 micrograms twice daily;
CHILD 4–12 years 50–100 micrograms twice daily
Mometasone furoate 200 micrograms twice daily
Note.
Dose adjustments may be required for some inhaler
devices,
see under individual preparations,
section 3.2
2.
Alternatives to inhaled corticosteroid are leukotriene receptor
antagonists,
theophylline,
inhaled cromoglicate,
or inhaled
nedocromil
3.
High-dose inhaled corticosteroids
Beclometasone dipropionate or
budesonide 0.4–1 mg
twice daily;
CHILD 5–12 years 200–400 micrograms twice
daily
Fluticasone propionate 200–500 micrograms twice daily;
CHILD 5–12 years 100–200 micrograms twice daily
Mometasone furoate 200–400 micrograms twice daily
Note.
Dose adjustments may be required for some inhaler
devices,
see under individual preparations,
section 3.2.
Failure to achieve control
with these doses is unusual,
see
also Side-effects of Inhaled Corticosteroids,
section 3.2
4.
Lung-function measurements cannot be used to guide
management in those under 5 years
Advice on the management of chronic asthma is based on the recommendations of the British Thoracic Society and Scottish
Intercollegiate Guidelines Network (updated June 2009);
updates available at www.brit-thoracic.org.uk
172
3.1 Bronchodilators
BNF 61
3
Respiratory system