A 24-year-old female comes for review

A 24-year-old female comes for review. She was diagnosed with asthma two years ago and is currently using a salbutamol inhaler 100mcg prn combined with beclometasone dipropionate inhaler 200mcg bd. Despite this her asthma is not well controlled. On examination her chest is clear and she has a good inhaler technique. Following NICE guidance, what is the most appropriate next step in management?

Increase beclometasone dipropionate to 400mcg bd

Switch steroid to fluticasone propionate

Add a leukotriene receptor antagonist

Add salmeterol

Add tiotropium

Asthma: management in adults

NICE released guidance on the management of asthma in 2017. These followed on quickly from the 2016 British Thoracic Society (BTS) guidelines. Given previous precedents where specialist societies or Royal colleges eventually default/contribute to NICE, we have followed the NICE guidance for the notes and questions.

One of the key changes is in ‘step 3’ - patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist, not a LABA

NICE do not follow the stepwise approach of the previous BTS guidelines. However, to try to make the guidelines easier to follow we’ve added our own steps:

Step Notes

Newly-diagnosed asthma|Short-acting beta agonist (SABA)|

Not controlled on previous step
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking|SABA + low-dose inhaled corticosteroid (ICS)|
|3|SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)|
|4|SABA + low-dose ICS + long-acting beta agonist (LABA)

Continue LTRA depending on patient’s response to LTRA|
|5|SABA +/- LTRA

Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS|
|6|SABA +/- LTRA + medium-dose ICS MART

OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA|
|7|SABA +/- LTRA + one of the following options:

  • increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART)
  • a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)
  • seeking advice from a healthcare professional with expertise in asthma|

Maintenance and reliever therapy (MART)

  • a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
  • MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

It should be noted that NICE does not advocate changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance.

Table showing examples of inhaled corticosteroid doses

Frustratingly, the definitions of what constitutes a low, moderate or high-dose ICS have also changed. For adults:

  • <= 400 micrograms budesonide or equivalent = low dose
  • 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose
  • > 800 micrograms budesonide or equivalent= high dose.