Asthma Treatment for adults >17

• No daytime symptoms.
• No night-time waking due to asthma.
• No need for rescue medication. 
• No asthma attacks.
• No limitations on activity including exercise.
• Normal lung function (FEV₁ and/or PEF > 80% predicted or best)
• Minimal side-effects from medication.
• Use an inhaled SABA (salbutamol) three times a week or less

Initial Asthma Appointment

• Asthma Control Questionnaire
• Lung function tests - spirometry or peak expiratory flow
• Arrange specialist referral if occupational asthma is suspected.
• Asthma Action Plan
• Ensure that the person is up to date with all routine vaccinations, including all childhood immunizations, and the annual influenza vaccination. 
• Patient Information  British Lung Foundation and Asthma UK.

Treatment

Reliever

• Short-acting beta-2 agonist (SABA )reliever therapy as required - salbutamol 
• Low Dose ICS - formorterol if needed

Preventer

Step 1

PRN low dose inhaled corticostroid (ICS)

• QVAR - beclomethasone - 100mcg bd, increased to 200mcg bd
• Clenil - beclomethasone - 200mcg bd, increased to  400mcg bd 
• Pumicort Turbohaler
• Flixotide
• Ciclesonide 160mcg one puff daily, can be increased/ decreased from this – particularly useful in patients with mouth/ throat side effects with other ICS medications, as this only becomes activated in lung tissue (This is not on the local formulary but is a good option with recognised benefits for some patients.  As long as the reason is noted, it is reasonable to use this despite being off formulary).

Step 2 

Daily low dose ICS

Step 3

 Add Leukotriene receptor antagonist (LTRA)

• LTRA =  Montelukast
  • 10mg in the evening
  • Review after 4 weeks - stop if ineffective, continue seasonally if effective
  • LTRA - Leukotriene receptor antagonist therapy
  • unique mechanism of action results in a combination of both bronchodilator and anti-inflammatory effects
  • Seek advice if experience neuropsychiatric reactions, including speech impairment and obsessive-compulsive symptom
  • particularly useful in atopic adults as there may be allergic triggers to their asthma

Step 4

Long-acting beta-2 agonist (LABA) & ICS

• Fostair - beclometasone & formoterol - 100/6 2 puffs bd increased to 200/6 2 puffs bd
• Symbicort - budesonide and formoterol - 100/6 2 puffs bd increased to  200/6 2 puffs BD

Step 5

• If asthma is uncontrolled on a MART regimen with a low maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy.)
• additional drug (for example, a muscarinic receptor antagonist or theophylline). Alternatively, a high maintenance dose of ICS may be appropriate. 

• Pregnant women - no changes, same treatment
• Spacers