Management of Asthma (BTS/SIGN Guidelines)

Summary of BTS/SIGN stepwise protocol for asthma treatment.




Aims of Pharmacological Management

To control the disease. Control is defined as:
  • No daytime symptoms
  • No night-time awakening due to asthma
  • No need for rescue medication
  • No asthma attacks
  • No limitations on activity including exercise
  • Normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best)
  • Minimal side effects

The Stepwise Approach

  • Start treatment at the step most appropriate to initial severity.
  • Achieve early control
  • Maintain control by: stepping up treatment as necessary/stepping down when control is good.
  • Before initiating a new drug therapy practitioners should check adherence with existing therapies, inhaler technique and eliminate trigger factors.
Stepping Down:
  • Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patient’s preference should all be taken into account.
  • Patients should be maintained at the lowest possible dose of inhaled corticosteroid. Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.

Asthma in Adults - Summary of Stepwise Management

Step

Reliever therapy

Additional therapiesFurther advice/therapy considerations
1: Mild Intermittent asthma  Inhaled short-acting ß2-agonist as required
  • Urgently assess patients prescribed >1 short-acting bronchodilator device per month
2: Regular preventer therapy  Inhaled short-acting ß2-agonist as required
Add inhaled corticosteroid* (200-800 mcg/day)
  • Start at dose appropriate to severity and titrate to lowest effective dose
  • Usual starting dose 400 mcg/day*
  • Initially divide dose twice daily except ciclesonide
  • Use once daily if good control established
3: Initial add-on therapy  Inhaled short-acting ß2-agonist as required

Inhaled corticosteroid* (200-800 mcg/day)

Add inhaled long-acting ß2-agonist (LABA)†

  • Good response to LABA - continue
  • Benefit with LABA but inadequate control - continue LABA and increase inhaled corticosteroid dose to 800 mcg/day* (if not already on this dose). If control still inadequate go to Step 4.
  • No response to LABA - discontinue LABA and increase inhaled corticosteroid dose to 800 mcg/day*. If control still inadequate, trial other therapies, eg, leukotriene receptor antagonists, sustained-release theophylline. If control still inadequate go to Step 4.
4: Persistent poor control  Inhaled short-acting ß2-agonist as required

Inhaled corticosteroid* (800 mcg/day).

Inhaled long-acting ß2-agonist (LABA)† [unless discontinued due to poor response]

  • Consider trials of increased inhaled corticosteroid dose up to 2000 mcg/day*

  • Consider trials of fourth drug, eg, leukotriene receptor antagonists, theophylline, slow-release ß2-agonist tablets

  • Consider referring to specialist

5: Continuous or frequent use of oral steroids  Inhaled short-acting ß2-agonist as required

High dose inhaled corticosteroid* (2000 mcg/day)

Use oral steroids at lowest dose for adequate control

  • Consider other treatments to minimise use of oral steroids
  • Refer to specialist

*Corticosteroid therapy

  • Doses in table refer to beclometasone dipropionate via an MDI - this should be prescribed by brand as some preparations are more potent than others; adjust dose with other corticosteroids (eg, fluticasone) and/or other devices
  • Inhaled corticosteroids should be considered for patients with an asthma attack in the past two years, using inhaled ß2-agonists three times a week or more, symptomatic three times a week or more, waking one night a week
  • Patients should be maintained on the lowest possible dose of inhaled steroids
  • Dose reduction should be slow eg, 25—50% dose reduction every 3 months
  • Risk of systemic side effects with long-term or frequent oral steroid therapy – monitor BP, check for signs of diabetes, hyperlipidaemia and osteoporosis. 
  • Higher doses of inhaled corticosteroids may be needed in patients who are smokers or ex-smokers
  • In selected adults either at Step 3 and poorly controlled or at Step 2 (above BDP 400 mcg/day and 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.

LABA

  • The use of combined corticosteroid/LABA inhalers is recommended in order to guarantee that LABAs are not taken without an inhaled corticosteroid and to improve inhaler adherence.
Asthma in Children Aged 5-12 Years - Summary of Stepwise Management
Step Reliever therapy Additional therapiesFurther advice/therapy considerations
1: Mild intermittent asthma  Inhaled short-acting ß2-agonist as required
  • Urgently assess patients prescribed >1 short-acting bronchodilator device per month
2: Regular preventer therapy  Inhaled short-acting ß2-agonist as required
Add inhaled corticosteroid* (200-400 mcg/day) [or add other preventer if inhaled corticosteroids cannot be used]
  • Start at dose appropriate to severity and titrate to lowest effective dose
  • Usual starting dose 200 mcg/day*
  • Initially divide dose twice daily except ciclesonide
  • Use once daily if good control established
3: Initial add-on therapy  Inhaled short-acting b2-agonist as required

Inhaled corticosteroid* (200-400 mcg/day)

 

Add inhaled long-acting ß2-agonist (LABA)† 

  • Good response to LABA - continue
  • Benefit with LABA but inadequate control - continue LABA and increase inhaled corticosteroid dose to 400 mcg/day* (if not already on this dose). If control still inadequate go to Step 4.
  • No response to LABA - discontinue LABA and increase inhaled corticosteroid dose to 400 mcg/day*. If control still inadequate, trial other therapies, eg, leukotriene receptor antagonists, sustained-release theophylline. If control still inadequate go to Step 4.
4: Persistent poor control  Inhaled short-acting ß2-agonist as required

Inhaled corticosteroid* (800 mcg/day)

Inhaled long-acting ß2-agonist (LABA)† [unless discontinued due to poor response]

  • Children under specialist care may benefit from a trial of higher doses of inhaled corticosteroid (>800 mcg/day*)
  • Refer to specialist before proceeding to Step 5.
5: Continuous or frequent use of oral steroids  Inhaled short-acting ß2-agonist as required

High dose inhaled corticosteroid* (800 mcg/day)

Use oral steroids at lowest dose for adequate control

  • Refer to respiratory paediatrician

*Corticosteroid therapy

  • Doses in table refer to beclometasone dipropionate via an MDI – this should be prescribed by brand as some preparations are more potent than others; adjust dose with other corticosteroids (eg, fluticasone) and/or other devices
  • Inhaled corticosteroids should be considered for patients with an asthma attack in the past two years, using inhaled ß2-agonists three times a week or more, symptomatic three times a week or more, waking one night a week
  • Patients should be maintained on the lowest possible dose of inhaled corticosteroids
  • Dose reduction should be slow eg, 25—50% dose reduction every 3 months
  • Risk of systemic side effects with long-term or frequent oral steroid therapy – monitor BP, check for signs of diabetes, hyperlipidaemia and osteoporosis. In children also monitor growth and screen for cataracts.

LABA

  • The use of combined corticosteroid/LABA inhalers is recommended in order to guarantee that LABAs are not taken without an inhaled corticosteroid and to improve inhaler adherence.
Asthma in Children Aged <5 Years - Summary of Stepwise Management
StepReliever therapyAdditional therapiesFurther advice/therapy considerations
1: Mild intermittent asthma  Inhaled short-acting ß2-agonist as required
  • Urgently assess patients prescribed >1 short-acting bronchodilator device per month
2: Regular preventer therapy  Inhaled short-acting ß2-agonist as required

Add inhaled corticosteroid* (200-400 mcg/day) [or add other preventer, eg, leukotriene receptor antagonists if inhaled steroids cannot be used]

  • Start at dose appropriate to severity and titrate to lowest effective dose
  • Usual starting dose 200 mcg/day*
  • Initially divide dose twice daily except ciclesonide
  • Use once daily if good control established
  • Higher nominal doses of inhaled corticosteroid may be required if there are problems in obtaining consistent drug delivery
3: Initial add-on therapy  Inhaled short-acting ß2-agonist as required

Inhaled corticosteroid* (200-400 mcg/day)

2-5 years - consider trial of leukotriene receptor antagonist.
<2 years - consider proceeding to Step 4.

4: Persistent poor control  Inhaled short-acting ß2-agonist as required Inhaled corticosteroid* (400 mcg/day)
  • Refer to respiratory paediatrician
*Corticosteroid therapy
  • Doses in table refer to beclometasone dipropionate via an MDI – this should be prescribed by brand as some preparations are more potent than others; adjust dose with other corticosteroids (eg, fluticasone) and/or other devices
  • Inhaled corticosteroids should be considered for patients with an asthma attack in the past two years, using inhaled ß2-agonists three times a week or more, symptomatic three times a week or more, waking one night a week
  • Patients should be maintained on the lowest possible dose of inhaled corticosteroids
  • Dose reduction should be slow eg, 25—50% dose reduction every 3 months
  • Risk of systemic side effects with long-term or frequent oral steroid therapy – monitor BP, check for signs of diabetes, hyperlipidaemia and osteoporosis. In children also monitor growth and screen for cataracts.
Adapted from the British Thoracic Society/Scottish Intercollegiate Guidelines Network (and others). British Guideline on the Management of Asthma (October 2014)
Available on the BTS web site (www.brit-thoracic.org.uk/) and the SIGN web site (www.sign.ac.uk)