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Asthma — SCE Respiratory MCQ

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HardSMART TherapyAsthmaSCE Respiratory

A 48-year-old woman with objectively confirmed asthma is reviewed after three oral-corticosteroid-treated exacerbations in the past 12 months. She uses budesonide/formoterol (Symbicort Turbohaler 200/6) as moderate-dose maintenance and reliever therapy: two inhalations twice daily, with additional inhalations as needed. Electronic dispensing data show 96% adherence, and directly observed inhaler technique is satisfactory. She does not smoke. Rhinitis and gastro-oesophageal reflux are controlled, and there is no clinical or radiological evidence of bronchiectasis or another alternative diagnosis. Her blood eosinophil count is 0.52 × 10^9/L (local upper reference limit 0.40 × 10^9/L), while fractional exhaled nitric oxide is 19 ppb. Spirometry shows persistent airflow obstruction with significant bronchodilator reversibility. Which is the most appropriate next management step?

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Correct answer: C — Refer now to a specialist asthma service while continuing moderate-dose MART

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

She has uncontrolled asthma despite verified adherence, satisfactory technique and moderate-dose MART, with important alternative causes of poor control addressed. The decisive discriminator is that her blood eosinophil count is raised, even though FeNO is not. The current BTS/NICE/SIGN pathway recommends specialist referral when asthma remains uncontrolled on moderate-dose MART and either FeNO or the blood eosinophil count is raised. Specialist assessment can confirm phenotype and determine eligibility for advanced treatment. A LAMA (B) or LTRA (C) trial is the recommended next pharmacological sequence when neither biomarker is raised; these should not delay referral in this eosinophilic case. Increasing treatment empirically to high-dose MART (D) is not the routine next step in the current UK pathway and would increase corticosteroid exposure without preceding specialist phenotyping. Replacing the anti-inflammatory reliever with SABA (E) removes the defining reliever component of MART and offers no solution to her exacerbation-prone disease. Moderate-dose MART should therefore be continued pending prompt specialist review rather than dismantled or escalated empirically.

Reference: Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN) — Recommendations (Published 27 November 2024; updated November 2025) — https://www.nice.org.uk/guidance/ng245/chapter/recommendations Inhaled corticosteroid doses for the BTS, NICE and SIGN asthma guideline (12 November 2025) — https://www.nice.org.uk/guidance/ng245/resources/inhaled-corticosteroid-doses-for-the-bts-nice-and-sign-asthma-guideline-pdf-13558148029