BTS/SIGN updates guidance on the management of asthma

Following a major review, the British Thoracic Society and Scottish Intercollegiate Guidelines Network have re-published their joint guidance on the management of asthma.

While the stepwise approach to management remains unchanged, the section on diagnosis has been re-written and new advice is provided on topics including difficult asthma.



  • In adults, spirometry is considered the preferred initial test to assess airflow obstruction.
  • Clinical features that influence the probability of asthma are listed for adults and children.
  • Patients with a high probability of asthma should be offered a trial of treatment; those with a low probability require further investigation of more likely alternative diagnoses or specialist referral.
  • In patients with an intermediate probability, management may include an explicit trial of treatments for a specified period, watchful waiting (in children) or further investigations, including reversibility tests or assessment of airway responsiveness.

Pharmacological management

  • The aim of management is to control the disease (defined as no daytime symptoms, no night time awakening due to asthma, no need for rescue medication, no exacerbations, no limitations on activity and normal lung function) with minimal side effects.
  • Once a patient is on stable therapy, combination inhalers have the advantage of ensuring a long-acting beta2 agonist is not used without inhaled steroid.
  • In adults at step 3 who are poorly controlled, the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short-acting beta2 agonist, in addition to its regular use as a controller treatment, is an effective treatment option but requires careful patient education.

Difficult asthma

  • Defined as persistent symptoms and/or frequent exacerbations despite treatment at step 4 or 5.
  • Systematically evaluate patients including confirmation of the diagnosis of asthma, identification of the mechanism of persisting symptoms and adherence with therapy.
  • Assessment should be facilitated through a dedicated multidisciplinary difficult asthma service.

The full guideline is available from and or there is a MIMS summary of the stepwise management in the Guidelines section.

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