guidelines

asthma

detailed summary of nice ng245 (2024/25): air therapy, mart regimes, and objective diagnosis.

last reviewed: 2026-02-13
based on: NICE NG245 (published 27 Nov 2024)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Paradigm Shift: "SABA-only" is dead. All patients need ICS. The preferred pathway (Adults/12+) is now AIR (Anti-Inflammatory Reliever) or MART to reduce exacerbation risk.
  • Diagnosis: Clinical suspicion is not enough. Require objective tests: FeNO (≥40 ppb) AND Spirometry (Obstructive + Reversibility >12% & >200ml).
  • Control: Define as no day symptoms, no night waking, no activity limit, and SABA use <3/week (if on SABA-based legacy track).

Diagnosis (The 1-2-3)

  • 1. FeNO: Positive if ≥40 ppb (Adults).
  • 2. Spirometry: Obstructive ratio (FEV1/FVC < 0.7).
  • 3. Reversibility (BDR): Improvement in FEV1 of ≥12% AND ≥200ml.
  • Note: If one test is negative but clinical suspicion is high, consider Peak Flow Diary (variability >20%) or trial of treatment (4-8 weeks).

Management Steps (Adults & 12+)

  • Step 1: AIR Therapy (Preferred initiation)
    • Use Low-dose ICS/Formoterol (e.g., Fostair 100/6 or Symbicort 200/6) as needed for relief.
    • Alternative (Legacy): Regular low-dose ICS daily + SABA prn.
  • Step 2: Low-dose MART
    • Daily maintenance low-dose ICS/Formoterol (e.g., 1 puff bd) PLUS same inhaler as reliever.
    • Legacy alternative: Regular low-dose ICS/LABA fixed dose + SABA prn.
  • Step 3: Moderate-dose MART
    • Increase maintenance dose (e.g., 2 puffs bd) using the same ICS/Formoterol device. Reliever usage continues.
    • Legacy alternative: Moderate-dose ICS/LABA fixed dose + SABA prn.
  • Step 4: LAMA / High-dose / Refer
    • Consider adding LAMA (e.g., Tiotropium) or increasing to high-dose ICS (specialist advice usually required).

Acute Exacerbation (Primary Care)

Prednisolone: 40-50mg od for 5 days. No taper needed if <3 weeks. Ensure safety netting: if no improvement in 24-48h, admit.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.