Aerosol Options1st lineSalbutamol 100mcg 2 puffs PRN

2nd lineSalbutamol Easibreathe®

100mcg 2 puffs PRN

Dry powder Options1st lineSalbutamol Easyhaler®

100mcg 2 puffs PRN

2nd lineTerbutaline Turbohaler®

500mcg 1 puff PRN

Dry powder Options1st line*DuoResp Spiromax®

(Budesonide/Formoterol) 160/4.5 1puff BD

2nd lineSeretide Accuhaler®

(Fluticasone/Salmeterol)100/50 1puff BD

Aerosol OptionFostair® (Beclometasone/Formoterol)100/6 1 puff BD

N.B. Use combination LABA and corticosteroid inhalers to avoid risk of LABA being used alone

Remember:• Always check inhaler technique, adherence, smoking status and eliminate trigger factors before moving up to next step.• Step up to gain control and step down once control achieved. Reduce combination inhaler strength when step down appropriate. Aim to

reduce inhaled steroid dose every 3 months by 25-50% each time.• Refer to Map of Medicine for further advice on management for patients at step 3 who do not respond to LABA.• All patients at steps 4 & 5 should be considered for secondary care respiratory specialist opinion.

Aerosol Options1st lineBeclomethasone Qvar®

50mcg 2 puffs BD

2nd lineBeclomethasone Qvar®

Easibreathe 50mcg 2 puffs BD

Dry powder OptionBudesonide Easyhaler®

100mcg 2 puffs BDNB:Prescribe beclomethasone inhalers by brand as not interchangeable. Qvar® 50mcg = 100mcg BDP-HFA

Guideline for the Management of Chronic Asthma in Adults

Dry Powder Options1st line*DuoResp Spiromax®

(Budesonide/Formoterol)i) 320/9 1 puff BDii) 320/9 2 puffs BD2nd lineSeretide Accuhaler®

(Fluticasone/Salmeterol)i) 250/50 1 puff BDii) 500/50 1 puff BDAerosol OptionFostair®

(Beclometasone/Formoterol)100/6 2 puffs BD

Then consider:•Montelukast 10mg, orally, once daily at nightOr •Theophylline MR (Uniphyllin®) 200–400mg, orally, twice daily.Referral to WUTH for specialist respiratory opinion

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Step 1Inhaled β2 agonist

PRN

Step 2Low dose inhaled

steroid

Reference: Scottish Intercollegiate Guidelines Network and The British Thoracic Society. The British Guideline on the Management of Asthma. October 2014

Step 5Specialist referral

For management of patients with poorly controlled asthma despite treatment up to step 4 recommend referral to WUTH for specialist respiratory opinion.

Further details of management of complex patients with asthma are available via BTS website

www.brit-thoracic.org.uk

Step 3Add in long acting β2 agonist (LABA)

This is an option for patients poorly controlled at step 2 or 3Dry Powder*DuoResp Spiromax® (Budesonide/Formoterol )160/4.5 1 or 2 puffs BD and 1 puff PRN (Max 8 puffs in 24 hours)

AerosolFostair ® (Beclometasone/ Formoterol) 100/61 puff BD and 1 puff PRN (Max 8 puffs in 24 hours)

Step 4High dose

inhaled corticosteroid

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Maintenance And Reliever Therapy

Guideline for the Management of Chronic Asthma in Adults V2 Authors: Nicola Stevenson (Respiratory Consultant), Helena Priest and Rachael Pugh (Pharmacists)Approved by MCGT December 2014 Review date: Sept 2018 Page 1 of 3

* Consider SymbicortTurbohaler® if DPI needed and unable to use Duoresp Spiromax ®

device

Step 2Usual starting dose is 200mcg BD of inhaled steroid as expressed in terms of beclometasone equivalent doses. Prior to 2009 the reference dose was beclometasone contained in CFC inhalers. Since CFC-beclometasone have been phased out the reference steroid will be BDP-HFA (Beclomethasone dipropionate - hydrofluroalkane) equivalent, e.g. Qvar 50mcg = 100mcg BDP-HFA equivalent.

NB. BTS guidelines allow starting dose to be varied between 100 – 400mcg BD but 200mcg BD should be applicable to the vast majorityof patients.

Step 3If a patient is poorly controlled on the initial dose of inhaled steroids they should be converted to a combination of inhaled steroid and Long Acting Beta 2 Agonists (LABA) rather than trying to increase inhaled steroid dose. The evidence base favours the addition of a LABA rather than increasing the dose of inhaled corticosteroids at this step.

On the rare occasions that a patient does not respond to the addition of a LABA, it should be stopped. If patients respond but control is still inadequate, their dose of inhaled corticosteroid should be increased to 400mcg BD of BDP-HFA equivalent.

Maintenance and Reliever Therapy at Step 2 or 3In selected patients at step 2 or 3 who are poorly controlled, the use of a single corticosteroid/formoterol inhaler as rescue medication (instead of a short acting beta 2 agonist) in addition to its regular use as a preventer treatment has been show to be an effective treatment option. When this management option is introduced the total regular dose of daily inhaled corticosteroids should not be decreased. If patients require the use of the inhaler for rescue therapy at least once daily, their regular preventer treatment should be reviewed.

Step 4 & beyondPatients being treated at step 4 and beyond can be extremely challenging. Consideration should be given to referring for a specialist opinion to WUTH.

Guideline for the Management of Chronic Asthma in Adults Authors: Nicola Stevenson (Respiratory Consultant), Helena Priest and Rachael Pugh (Pharmacists)Approved by MCGT: Dec 14 Review date: Dec 2017 Page 2 of 3

Guideline for the Management of Chronic Asthma in Adults

Inhaled steroid LABAequivalent dose compared to BDP-HFAequivalent

Beclometasone (dry powder) 200mcg 200mcg x

QVAR 100mcg 200mcg x

Clenil 200mcg 200mcg x

Budesonide 200mcg 200mcg x

Fostair 100/6 250mcg 6mcg formoterol

DuoResp Spiromax 160/4.5 200mcg ≡6mcg formoterol

DuoResp Spiromax 320/9 400mcg ≡12mcg formoterol

Seretide Evohaler 125 250mcg 25mcg salmeterol

Seretide Evohaler 250 500mcg 25mcg salmeterol

Seretide Accuhaler 250 500mcg 50mcg salmeterol

Seretide Accuhaler 500 1000mcg 50mcg salmeterol

INHALER CONSTITUENT COMPARISONS

Guideline for the Management of Chronic Asthma in Adults Authors: Nicola Stevenson (Respiratory Consultant), Helena Priest and Rachael Pugh (Pharmacists)Approved by MCGT: Dec 2014 Review date: Dec 2017 Page 3 of 3

Care Guidelines for the Management of Chronic Asthma in Adults