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Asthma — MSRA MCQ

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Moderateall topics relevant for this examAsthmaMSRA

A 34-year-old woman with objectively confirmed asthma attends for review. She uses beclometasone dipropionate 200 micrograms twice daily and salbutamol as needed. Inhaler technique is satisfactory and prescription records indicate good adherence. Over the past 6 weeks, she has had wheeze and chest tightness on 4 days each week, uses salbutamol on most of those days, and wakes with symptoms twice monthly. She required one course of oral prednisolone for an exacerbation 8 months ago. She has no current infective symptoms and is not acutely unwell. What is the most appropriate pharmacological change now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Change to low-dose inhaled corticosteroid/formoterol maintenance-and-reliever therapy

Explanation lettering: E = shown as A · A = shown as E

Her asthma is uncontrolled despite verified adherence and satisfactory inhaler technique with regular low-dose inhaled corticosteroid (ICS) plus a short-acting beta2 agonist (SABA). Symptoms on most weeks, reliever use and nocturnal waking demonstrate inadequate control; the previous oral corticosteroid-treated exacerbation further supports stepping up treatment. BTS/NICE/SIGN guidance advises considering a change to low-dose ICS/formoterol maintenance-and-reliever therapy (MART) in people aged 12 years and over whose asthma is not controlled on regular low-dose ICS plus as-needed SABA. Adding a long-acting beta2 agonist while retaining SABA (B) is a plausible traditional step-up regimen, but MART is the recommended preferred sequencing option in this situation. Increasing ICS dose alone (C) does not follow the recommended step-up sequence. A leukotriene receptor antagonist (D) is considered later, as an add-on trial for asthma uncontrolled despite moderate-dose MART when relevant inflammatory markers are not raised. Specialist referral (E) is reserved for asthma that remains uncontrolled despite moderate-dose MART and trials of both leukotriene receptor antagonist and long-acting muscarinic antagonist treatment.

Reference: Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) — Recommendations (2024; updated November 2025) — https://www.nice.org.uk/guidance/ng245/chapter/recommendations Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) — Recommendations (2024; updated November 2025) — https://www.nice.org.uk/guidance/ng245/chapter/recommendations