Chronic Asthma Management: High-Yield Revision for MRCP, UKMLA and MSRA (2026)

Chronic asthma management was transformed by the 2024 joint guideline, which moved away from the reliever-first ladder that examiners taught for decades. This guide covers chronic asthma management in adults as examiners now frame them, to the current standard (BTS/NICE/SIGN, NG245). Follow current guidance and local protocols in practice; this reflects guidance as of mid-2026.

What asthma is

Asthma is a chronic inflammatory airway disease causing variable, reversible airflow obstruction, with symptoms of wheeze, breathlessness, chest tightness and cough that vary over time and in intensity. It is often associated with atopy, and with eosinophilic airway inflammation that responds to inhaled corticosteroids — a fact that underpins the modern treatment approach. Common triggers include allergens, viral infections, exercise, cold air, smoke, and certain drugs such as non-steroidal anti-inflammatories and beta-blockers. A personal or family history of atopy — eczema, hay fever or allergy — supports the diagnosis, and occupational exposures should be considered in adults whose symptoms improve away from work.

Diagnosis

The 2024 guideline emphasises objective testing rather than diagnosis on symptoms alone. In adults, the diagnosis is supported by markers of eosinophilic inflammation and airflow variability: a raised fractional exhaled nitric oxide (FeNO), a raised blood eosinophil count, bronchodilator reversibility on spirometry, or peak-flow variability. No single test is both sensitive and specific, so a combination is often needed, and inhaled corticosteroids can lower FeNO and mask spirometry. If a patient is acutely unwell, treat first and test once stable. Diagnosis is often built over more than one visit, combining the history with whichever objective tests are available, since access to FeNO and spirometry varies between settings.

The shift away from SABA

This is the single most important update to learn. For people aged 12 and over, a short-acting beta-agonist (SABA) used alone as a reliever is no longer recommended, because reliance on it — without an inhaled steroid — is associated with worse outcomes and asthma deaths. The cornerstone is now an inhaled corticosteroid combined with formoterol, used either as needed (anti-inflammatory reliever, or AIR) or regularly as maintenance and reliever therapy (MART). Formoterol's rapid onset is what allows the same inhaler to act as both preventer and reliever.

The chronic ladder for adults

For people aged 12 and over, treatment escalates as follows:

Start with as-needed AIR: a low-dose ICS/formoterol inhaler taken as needed for symptom relief, for newly diagnosed asthma.
Step up to low-dose MART: if asthma is not controlled on as-needed AIR. MART means a single low-dose ICS/formoterol inhaler used both as a regular maintenance dose and as the reliever.
Step up to moderate-dose MART: if not controlled on low-dose MART.
If still not controlled on moderate-dose MART despite good adherence: check the FeNO and the blood eosinophil count. If either is raised, refer to a specialist. If neither is raised, trial a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic antagonist (LAMA) added to moderate-dose MART for 8 to 12 weeks, and refer if control is not achieved.

If a patient presents highly symptomatic — for example with regular nocturnal waking — or with a severe exacerbation, start at low-dose MART rather than as-needed AIR, treating the acute episode as needed, and consider stepping down later once control is established. Stepping down once asthma is stable is part of good management, reducing treatment to the lowest dose that maintains control, typically by moving from MART back to as-needed AIR.

Monitoring and review

Review at least annually, and after every exacerbation. Assess control by asking about daytime symptoms, nocturnal waking, reliever use and activity limitation, and check exacerbations, oral steroid courses and any hospital or emergency attendance. Check inhaler technique and adherence at every step, as poor technique is a common cause of apparent treatment failure. The guideline advises against routine peak-flow monitoring unless there is a person-specific reason, and reminds prescribers of the neuropsychiatric warning associated with montelukast. A written personalised asthma action plan should be provided and reviewed, and every contact is an opportunity to check technique and adherence.

High-yield exam points and traps

SABA-only reliever therapy is no longer recommended for people aged 12 and over — the central 2024 change.
The cornerstone is ICS/formoterol, used as AIR (as needed) or MART (maintenance and reliever).
MART means one ICS/formoterol inhaler used for both regular maintenance and as the reliever.
Before referral for uncontrolled asthma, check FeNO and eosinophils; if neither is raised, trial an LTRA or LAMA.
Start at low-dose MART, not as-needed AIR, for a highly symptomatic patient.
Diagnosis should be supported by objective tests, and inhaled steroids can lower FeNO and mask spirometry.
Reliever overuse — three or more inhalers a year under the old model — flags poor control and a higher risk of attacks.

A few common questions

What replaced SABA-only treatment in asthma? Inhaled corticosteroid combined with formoterol — used as needed (AIR) or as regular maintenance and reliever therapy (MART); a SABA used alone is no longer recommended for people aged 12 and over.

What is MART? Maintenance and reliever therapy — a single low-dose ICS/formoterol inhaler used both as a regular daily dose and as the reliever for symptoms.

What is the initial step for newly diagnosed adult asthma? As-needed AIR — a low-dose ICS/formoterol inhaler taken as needed for symptom relief — unless the patient is highly symptomatic, when low-dose MART is started.

How is asthma diagnosed under the 2024 guideline? With objective tests — FeNO, blood eosinophil count, bronchodilator reversibility or peak-flow variability — supporting a characteristic history, since no single test is definitive.

When should asthma be referred to a specialist? Asthma should be referred to a specialist when it is uncontrolled on moderate-dose MART and a raised FeNO or eosinophil count is found, or when control is not achieved after trialling an LTRA or LAMA.

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