Adult asthma

The 2024 British Thoracic Society (BTS), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on asthma management provide the following recommendations regarding adult asthma.¹

Note that these recommendations differ in several areas from prior guidelines.

General principles of adult asthma management

• Step up/down treatment according to disease severity to maintain good control and minimise drug-related side-effects.

• Start at the step most fitting to the initial severity of the asthma.

• Treatment plans and goals should be negotiated with the patient but usual aims would be to minimise impact of adult asthma symptoms on life, reduce reliance on reliever medication and prevent severe exacerbations.

• Self-management education including individualised written asthma action plans should be offered.

• Always check concordance with medication/existing action plan, effective inhaler technique and the presence/absence of trigger factors before initiating new drug therapy.

• It is very important to consider the upper respiratory tract when treating asthma. It is much more difficult to treat asthma successfully if co-existing allergic rhinitis is not adequately controlled.²

See also the separate Occupational asthma, Asthma (bronchial) and Acute severe asthma and status asthmaticus articles.

Asthma reviews

Routine asthma care is largely carried out in primary care. Practices must keep a register of patients with asthma to ensure adequate follow-up and audit. All patients with asthma should be reviewed at least annually, more often if disease is less well controlled or recently diagnosed. Reviews should be carried out by a nurse or doctor with appropriate and up-to-date training and should include:

• Current symptoms using objective measures:
  

  The 'three questions' of the Royal College of Physicians (RCP) are widely used:

  • In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)?

  • Have you had your usual asthma symptoms (eg, cough, wheeze, chest tightness, shortness of breath) during the day?

  • Has your asthma interfered with your usual daily activities (eg, school, work, housework)?

  Note: one 'yes' indicates medium morbidity and two or three 'yes' answers indicate high morbidity.

  
  Alternatives include the Asthma Control Questionnaire, Asthma Control Test and Mini Asthma Quality of Life Questionnaire.

• Record an up-to-date smoking status; offer smoking cessation advice and support where appropriate.

• Record any time off work or school due to asthma.

• Record any acute exacerbations since last seen, and the number of courses of oral corticosteroids needed.

• Record any admissions to hospital or attendances at an Emergency Department for asthma.

• Check medication use - a prescription count can indicate overuse/underuse of medication, inhaler and spacer, problems and side-effects. The use of more than two canisters of short-acting beta₂ agonist per month - or 10-12 puffs per day - is associated with poorly controlled and higher-risk asthma.

• Check immunisation (pneumococcal/influenza) status.

• Address any educational needs.

• Provide/update a written action plan.

• If available, consider FeNO measurement at the time of review.

  • A raised FeNO measurement may indicate poor adherence to inhaled corticosteroids, or that the dose of inhaled corticosteroids is too low.

  • Conversely, a normal FeNO level and excellent symptom control may suggest that maintenance therapy can be reduced.

• Regular peak expiratory flow (PEF) monitoring is not recommended as a method of assessing asthma control routinely, but may be considered if individual circumstances warrant.

  • NICE made this recommendation on the basis that available research evidence shows that regular PEF monitoring in asthma is associated with worse outcomes; hence, it should not be used routinely.

  • However, there is a minority of people with asthma where regular PEF measurement is helpful, such as in those who find it difficult to recognise symptoms of worsening asthma and may therefore delay seeking treatment, or those for whom PEF monitoring is an important part of their asthma management plan.

• Agree duration of subsequent follow-up and ensure the patient is aware of how to seek help if their asthma deteriorates.

Asthma action plans³

All patients with asthma should have an individually tailored action plan to include:

• What medication they are on and how it works.

• How to titrate their medication in times of exacerbation and when to seek help.

• How to manage severe asthma symptoms.

• When to contact emergency services.

NICE has also advised that approaches to reducing air pollution (both indoors and outdoors) should be part of this plan, as pollution can trigger and exacerbate asthma. These should include:⁴

• Approaches to minimising indoor air pollution and reducing exposure to outdoor air pollution should be included in a personalised action plan because pollution can trigger and exacerbate asthma.

• Advising patient about indoor air pollutants - including nitrogen dioxide, damp, mould, particulate matter and volatile organic compounds (VOCs).

• If mould or other indoor pollutants could be exacerbating a patient's symptoms, they should be helped to request a housing assessment from the local authority.

• Avoiding household sprays, air fresheners or aerosols and using non-spray alternatives, if patients' symptoms are triggered by these.

The use of remote technology such as telephone reviews, SMS and the internet has received mixed response from patients and healthcare professionals alike.⁵ However, current asthma guidelines still include telephone calls and IT-based education and monitoring as appropriate strategies to aid self-management. ¹

Non-drug treatment for adult asthma⁶

All people with asthma (and/or their carers) should be offered self-management education (including a written personalised asthma action plan as discussed above) and be supported by regular professional reviews. Self-management could include:

• Smoking cessation. Smoking exacerbates asthma symptoms. It increases the risk of persistent asthma in teenagers who smoke. Clear personalised advice should be given to stop smoking and help provided with nicotine replacement therapy, etc, where appropriate.

• Weight reduction in obese patients improves asthma symptoms and should be encouraged.

• Breathing exercise programmes can be offered to people with asthma as an adjuvant to pharmacological treatment, to improve quality of life and reduce symptoms.

• Allergen avoidance. There is little evidence that reducing allergen exposure reduces morbidity from asthma and it does not appear to be a cost-effective treatment for asthma. Avoiding house dust mite allergen (bed covers, carpet removal, high-temperature washing of bedding, dehumidification and use of acaricides on soft furnishings) requires commitment beyond what is possible in most households. Similarly, cat and dog allergens are potent triggers for many people's asthma. Again, however, observational evidence that removal of the pet from the household improves asthma control, is lacking. Nonetheless, expert consensus usually advocates their removal.

Dietary modifications (use of probiotics, antioxidants, fish oils/lipid supplements, magnesium) and complementary therapies are not currently supported by the guidelines.

Drug treatment¹

Step up/down management of chronic asthma in people aged 12 and over:

Step 1: as-needed anti-inflammatory reliever (AIR) therapy

For people with newly diagnosed asthma, prescribe a low-dose inhaled corticosteroid/formeterol combination inhaler to be used as needed for symptom relief (anti-inflammatory reliever or AIR therapy).

Currently, the only inhalers licensed for use as AIR therapy in the UK are:

• Wock AIR 160/4.5.

• DuoResp Spiromax 160/4.5.

• Symbicort Turbohaler 200/6.

Step 2: low-dose MART

For people whose asthma symptoms are not sufficiently controlled with as-needed AIR therapy, start treatment with low-dose maintenance and reliever therapy (MART). This should also be used as the initial treatment for people who are highly symptomatic at presentation, and for people who present with a severe asthma exacerbation.

MART involves the use of a single combination inhaler containing an inhaled corticosteroid and formeterol. This inhaler should be used regularly (usually twice a day) and then additionally as-required for asthma symptoms when they are present.

Note that combination inhalers used for MART must contain formeterol as the long-acting beta agonist. Formeterol has a rapid onset of action, unlike other long-acting beta agonists, making it suitable for use as acute relief of asthma symptoms.

Step 3: moderate-dose MART

If asthma is not controlled with low-dose MART, escalate to moderate-dose MART.

Step 4: further options and referral

If asthma is not controlled with moderate-dose MART despite good adherence, NICE recommends the following strategies:

• Check fractional exhaled nitric oxide (FeNO) levels if available, and blood eosinophil count. If either is raised, refer to a specialist in asthma care.

  • The rationale for this recommendation is that elevated FeNO levels or eosinophilia at this stage of treatment indicates a relatively high risk of adverse outcomes.

• If neither FeNO or blood eosinophils are raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic antagonist (LAMA) in addition to moderate-dose MART.

  • Give the additional medication for a trial period of 8 to 12 weeks unless there are side-effects.

  • If asthma is controlled with the additional medication, continue the treatment.

  • If control has improved but is still inadequate, continue the treatment and start a trial of the other medication (LTRA or LAMA).

  • If control has not improved, stop the medication and start a trial of the alternative medication.

• If control is not achieved despite moderate-dose MART and trials of a LTRA and LAMA, refer to an asthma specialist.

Transferring people from other treatment pathways

These recommendations differ significantly from previous NICE guidance, which recommended a 'conventional' treatment algorithm using a regular preventer (ICS, alone or in combination with a long-acting beta agonist (LABA)) and an as-needed reliever (SABA), plus supplementary therapy (LTRA) in some cases.

As discussed above, NICE recommends that SABA monotherapy should not be used to treat asthma, and people currently prescribed SABA monotherapy should be changed to AIR therapy.

Otherwise, people whose asthma symptoms are well-controlled on their current treatment can remain on it. If their asthma symptoms are not well-controlled, NICE suggests moving them onto low- or moderate-dose MART (depending on their current dose of ICS).

Stepping down

Therapy should be reviewed annually at a minimum. If asthma symptoms are well-controlled, consider reducing maintenance therapy, taking into account the risks and benefits of doing so and the patient's preferences.

Allow at least 8 to 12 weeks before considering a further treatment reduction.

If considering a step-down from low-dose ICS plus SABA as-needed, or low-dose MART, step down to as-needed AIR therapy.

Biologic treatments - monoclonal antibodies

There are currently six biological treatments approved for use in the UK and available on the NHS to treat severe asthma. All can be started by specialists under certain criteria. All are injections, apart from reslizumab which is delivered via intravenous infusion.

These are:

• Omalizumab (Xolair®).

• Mepolizumab (Nucala®).

• Reslizumab (Cinqaero®).

• Benralizumab (Fasenra®).

• Dupilumab (Dupixent®).

• Tezepelumab (Tezspire®).

Omalizumab⁷

NICE recommends omalizumab as an option for treating severe persistent confirmed allergic IgE-mediated asthma as an add-on to optimised standard therapy in people aged 6 years and older who need continuous or frequent treatment with oral corticosteroids (defined as four or more courses in the previous year). Omalizumab should only be initiated by a specialist.

Optimised standard therapy is defined as a full trial of and, if tolerated, documented compliance with high-dose ICS, LABAs, LRTAs, theophyllines, oral corticosteroids, and smoking cessation if clinically appropriate.

Mepolizumab⁸

NICE has issued recommendations on the use of mepolizumab in patients with severe eosinophilic asthma. It is only recommended as an add-on therapy to patients with severe refractory asthma not controlled with an optimised standard treatment plan. It is given as an injection every four weeks.

Mepolizumab may be suitable for age 6 years and above. Only children aged 12 years or above can be given treatments to use at home.

In addition, they must fulfil the following criteria:

• Blood eosinophil count has been recorded as at least 300 cells/mcl or more and they have had at least four exacerbations needing systemic corticosteroids in the previous year, or had continuous oral corticosteroids of at least the equivalent of prednisolone 5 mg per day over the previous six months; or

• Blood eosinophil count has been recorded as at least 400 cells/mcl and they have had at least three exacerbations needing systemic corticosteroids in the previous year.

Reslisumab⁹

Reslisumab is suitable for adults aged 18 and over. It is given as an intravenous infusion every four weeks.

Patients must fulfil the following criteria:

• Eosinophil count has reached 400 cells or more and they have had at least three or more asthma attacks needing steroid tablets or injections in the past 12 months.

• Patient is based in England, Wales or Northern Ireland. It's not available in Scotland yet.

Benralizumab¹⁰

Benralizumab is suitable for adults aged 18 and over. It is given as an injection every four weeks for the first three doses, then eight-weekly thereafter.

Patients must fulfil the following criteria:

• Eosinophil count has reached 300 cells or more; and

• Had four or more asthma attacks needing steroid tablets or injections in the past 12 months; or

• Had continuous steroids of at least 5 mg prednisolone per day over the previous six months.

If the patient has responded well to benralizumab after 12 months, they can continue on it with a yearly review.

Dupilumab¹¹

Dupilumab as an option for add-on maintenance therapy in severe asthma with type 2 inflammation that is inadequately controlled in people aged 12 years and over, despite maintenance therapy with high-dose inhaled corticosteroids and another maintenance treatment, if:

• The dosage used is 400 mg initially and then 200 mg subcutaneously every other week.

• The person has agreed to and follows an optimised standard treatment plan.

• The person has a blood eosinophil count of at least 150 cells/mcl and FeNO of at least 25 parts/billion, and has had at least four or more exacerbations in the previous 12 months.

• The person is not eligible for mepolizumab, reslizumab or benralizumab, or has asthma that has not responded adequately to these biological therapies.

Tezepelumab¹²

NICE has recommended tezepelumab as an add-on to maintenance treatment in people 12 years and over with severe asthma, when treatment with high-dose inhaled corticosteroids plus another maintenance treatment has not worked well enough to treat severe asthma.

Criteria for specialist prescribing are:

• The person has had three or more exacerbations in the previous year.

• The person is taking maintenance oral corticosteroids.

In addition, tezepelumab should be stopped if the rate of severe asthma exacerbations, or the maintenance oral corticosteroid dose, has not been reduced by at least 50% at 12 months.

Management of acute asthma

See the separate Acute severe asthma and status asthmaticus article - treat as an emergency.

NICE recommends that, for individuals using ICS in single inhalers, an increased-dose ICS for 7 days can be incorporated into self-management plans for asthma, to be used when asthma control deteriorates. ICS doses can be quadrupled in this setting, up to the maximum licensed daily dose.

Asthma in pregnancy¹¹³

Asthma's course in pregnancy is very variable. The risk of deterioration is highest in those with severe asthma but, equally approximately, a third of women with asthma improve symptomatically during pregnancy. Up to a fifth of pregnant women with asthma require emergency treatment, of which two thirds require hospitalisation.

Well-controlled asthma minimises the risk of fetal and maternal complications. Pre-pregnancy, optimise control and emphasise the importance of continuing medication in pregnancy. Closely monitor pregnant women with asthma, so that appropriate changes to their treatment can be quickly implemented in response to changed symptoms.

Treat exacerbations vigorously, in particular ensuring oxygen saturation is maintained above 95%. In general, asthma medications are believed to be safe in pregnancy - women should be reassured regarding treatments. Inhaled short- and long-acting beta₂ antagonists, ICS and oral and intravenous theophyllines can be used as normal during pregnancy.

Oral corticosteroids should be used, if necessary, to treat exacerbations of asthma in pregnancy. The benefits of this outweigh the risks.

LTRAs and LAMAs should be continued during pregnancy if they are necessary to achieve asthma control.

Acute severe asthma in pregnancy is an emergency and should be treated vigorously in hospital.

Smoking cessation and breastfeeding should be particularly encouraged in women with asthma. Asthma drugs can be used as normal in breastfeeding women.

Inhaler and spacer devices

See also the separate Which device in asthma? and Nebulisers in general practice articles.

Asthma management can be confusing given the array of devices, masks and spacers used to deliver inhaled drugs. When considering which inhaler device, consider manual dexterity and other necessary abilities to activate a particular device, factors such as portability and convenience and the patient's willingness to use a particular device.

Whenever an inhaler is prescribed, training should be given and technique checked regularly to ensure that it is being used correctly.

Inhaler choice depends on the drug, the patient's ability to use the device, the patient's preferences, the cost of the inhaler and the environmental impact of the inhalers.

Pressured metered dose inhalers (pMDIs) have historically been the first choice for inhalers. However, these have a considerably higher carbon footprint than other inhalers, and therefore other types, such as dry powder inhalers (DPIs) and soft mist inhalers (SMIs) are encouraged where clinically appropriate and acceptable to the patient.

If using a pMDI, large-volume spacer devices are useful for increasing drug delivery to the lungs and may be used for all patients but are strongly indicated for those who have difficulty co-ordinating pMDI activation with inhalation and those on high doses of ICS (>800 micrograms/day). Portability of spacers can be an issue. In the very young, a face mask should be used with the pMDI and spacer combination, until the spacer mouthpiece can be reliably used. If this is ineffective, a nebuliser should be considered.

Referral¹⁴

The decision to refer is influenced by local referral pathways, the individual and the experience of the primary healthcare provider. In addition to respiratory physicians and paediatricians with a specialised interest in respiratory medicine, other specialists such as dieticians, physiotherapists, occupational therapists and respiratory nurse specialists may be involved in the management of asthma. Admit or refer adults for specialist assessment or further investigation in the following situations:

• Severe acute asthma.

• The diagnosis is unclear or in doubt:

  • Unexpected clinical findings (for example, crackles, clubbing, cyanosis, cardiac disease).

  • Persistent non-variable breathlessness.

  • Monophonic, unilateral or fixed wheeze or stridor.

  • Persistent chest pain or atypical features.

  • Prominent systemic features (for example, weight loss, myalgia, fever).

  • Persistent cough or sputum production.

  • Spirometric or PEFR measurements that do not fit the clinical picture (for example, unexplained restrictive spirometry).

• Suspected occupational asthma.

• Non-resolving pneumonia.

• Inadequate response to maximum guideline treatment.