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Overview

  • This guideline covers diagnosing, monitoring and managing asthma in adults, young people and children. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks. It does not cover managing severe asthma or acute asthma attacks. The investment and training required to implement the guideline will take time. In the meantime, primary care services should implement what they can of the recommendations, using currently available approaches to diagnosis until the infrastructure for objective testing is in place
  • This guideline is the basis of QS25 and QS181
  • This section is part 2 of the NICE Asthma: diagnosis, monitoring and chronic asthma management guideline

Principles of pharmacological treatment

  • Take into account the possible reasons for uncontrolled asthma, before starting or adjusting medicines for asthma in adults, young people and children. These may include:
    • alternative diagnoses
    • lack of adherence
    • suboptimal inhaler technique
    • smoking (active or passive)
    • occupational exposures
    • psychosocial factors
    • seasonal or environmental factors
  • After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks (see recommendations on monitoring asthma control)
  • If inhaled corticosteroid (ICS) maintenance therapy is needed, offer regular daily ICS rather than intermittent or ‘when required’ ICS therapy
  • Adjust the dose of ICS maintenance therapy over time, aiming for the lowest dose required for effective asthma control
  • Ensure that a person with asthma can use their inhaler device:
    • at any asthma review, either routine or unscheduled
    • whenever a new type of device is supplied

Pharmacological treatment pathway for adults (aged 17 years and over)

  • This section is for people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance

Pharmacological treatment of chronic asthma in adults aged 17 and over

Pharmacological treatment of chronic asthma in adults aged 17 and over

  • Offer a short-acting beta2 agonist (SABA) as reliever therapy to adults (aged 17 years and over) with newly diagnosed asthma
  • For adults (aged 17 years and over) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone
  • Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 years and over) with:
    • symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
    • asthma that is uncontrolled with a SABA alone
  • If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks
  • If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:
    • discuss with the person whether or not to continue LTRA treatment
    • take into account the degree of response to LTRA treatment
  • If asthma is uncontrolled in adults (aged 17 years and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person’s ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose
  • If asthma is uncontrolled in adults (aged 17 years and over) 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)
  • If asthma is uncontrolled in adults (aged 17 years and over) on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:
    • increasing the ICS to a high maintenance dose (this should only be offered as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
    • a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline)or
    • seeking advice from a healthcare professional with expertise in asthma

Pharmacological treatment pathway for children and young people aged 5 to 16 years

  • This section is for children and young people with newly diagnosed asthma or asthma that is uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children and young people whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow guidance

Pharmacological treatment of chronic asthma in children and young people aged 5 to 16

Pharmacological treatment of chronic asthma in children and young people aged 5 to 16 years

  • Offer a SABA as reliever therapy to children and young people (aged 5 to 16 years) with newly diagnosed asthma
  • For children and young people (aged 5 to 16 years) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone
  • Offer a paediatric low dose of an ICS as the first-line maintenance therapy to children and young people (aged 5 to 16) with:
    • symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
    • asthma that is uncontrolled with a SABA alone
  • If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS as maintenance therapy, consider an LTRA* in addition to the ICS and review the response to treatment in 4 to 8 weeks
  • If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA in combination with the ICS
  • If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric low dose of ICS and a LABA as maintenance therapy, consider changing their ICS and LABA maintenance therapy to a MART regimen with a paediatric low maintenance ICS dose. Ensure that the child or young person is able to understand and comply with the MART regimen
  • If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a MART regimen with a paediatric low maintenance ICS dose, consider increasing the ICS to a paediatric 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)
  • If asthma is uncontrolled in children and young people (aged 5 to 16 years) on a paediatric moderate maintenance ICS dose with LABA (either as MART or a fixed-dose regimen), consider seeking advice from a healthcare professional with expertise in asthma and consider either:
    • increasing the ICS dose to paediatric high maintenance dose (only as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
    • a trial of an additional drug (for example, theophylline)

Pharmacological treatment pathway for children under 5 years

  • It can be difficult to confirm asthma diagnosis in young children, therefore these recommendations apply to children with suspected or confirmed asthma. Asthma diagnosis should be confirmed when the child is able to undergo objective tests (see diagnosing asthma in young children in Asthma diagnosis and monitoring)
  • This section is for children under 5 years with newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment. Where the recommendations represent a change from traditional clinical practice, children whose asthma is well controlled on their current treatment should not have their treatment changed purely to follow this guidance

Pharmacological treatment of chronic asthma in children under 5

Pharmacological treatment of chronic asthma in children under 5 years of age

  • Offer a SABA as reliever therapy to children under 5 with suspected asthma. This should be used for symptom relief alongside all maintenance therapy
  • Consider an 8‑week trial of a paediatric moderate dose of an ICS in children under 5 years with:
    • symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
    • suspected asthma that is uncontrolled with a SABA alone
  • After 8 weeks, stop ICS treatment and continue to monitor the child’s symptoms:
    • if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
    • if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
    • if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS
  • If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as maintenance therapy, consider an LTRA§ in addition to the ICS
  • If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS and an LTRA as maintenance therapy, stop the LTRA and refer the child to a healthcare professional with expertise in asthma for further investigation and management

Adherence

  • For guidance on managing non-adherence to medicines in people with asthma, see the NICE guideline on medicines adherence

Self-management

  • Offer an asthma self-management programme, comprising a written personalised action plan and education, to adults, young people and children aged 5 and over with a diagnosis of asthma (and their families or carers if appropriate)
  • Consider an asthma self-management programme, comprising a written personalised action plan and education, for the families or carers of children under 5 with suspected or confirmed asthma

Increasing ICS treatment within a self-management programme

  • Within a self-management programme, offer an increased dose of ICS for 7 days to adults (aged 17 and over) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly outline in the person’s asthma action plan how and when to do this, and what to do if symptoms do not improve. When increasing ICS treatment:
    • consider quadrupling the regular ICS dose
    • do not exceed the maximum licensed daily dose
  • Within a self-management programme, consider an increased dose of ICS for 7 days for children and young people (aged 5 to 16) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly outline in the person’s asthma action plan how and when to do this, and what to do if symptoms do not improve. When increasing ICS treatment:
    • consider quadrupling the regular ICS dose
    • do not exceed the maximum licensed daily dose
  • For children and young people aged 5 to 16 with a diagnosis of asthma, include advice in their self-management programme on contacting a healthcare professional for a review if their asthma control deteriorates

  • For children and young people aged 5 to 16 with deteriorating asthma who have not been taking their ICS consistently, explain that restarting regular use may help them to regain control of their asthma. The evidence for increasing ICS doses to self-manage deteriorating asthma control is limited

Decreasing maintenance therapy

  • Consider decreasing maintenance therapy when a person’s asthma has been controlled with their current maintenance therapy for at least 3 months
  • Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of decreasing maintenance therapy
  • When reducing maintenance therapy:
    • stop or reduce dose of medicines in an order that takes into account the clinical effectiveness when introduced, side effects and the person’s preference
    • only consider stopping ICS treatment completely for people who are using low dose ICS alone as maintenance therapy and are symptom free
  • Agree with the person (or their family or carer if appropriate) how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and a follow‑up with a healthcare professional
  • Review and update the person’s asthma action plan when decreasing maintenance therapy

Risk stratification

  • Consider using risk stratification to identify people with asthma who are at increased risk of poor outcomes, and use this information to optimise their care. Base risk stratification on factors such as non-adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled care for asthma

* At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.

At the time of publication (November 2017), not all LABAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.

At the time of publication (November 2017), MART regimens did not have a UK marketing authorisation for use in children and young people (aged under 12 years) for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information.

§ At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children and young people aged under 18 years for this indication.

© NICE 2018. Chronic asthma management. Available from: www.nice.org.uk/guidance/NG80. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

Published date: 

Last updated: 12 February 2020. 

NICE asthma guideline: diagnosis and monitoring