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Asthma — SCE Respiratory MCQ

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HardLong-Acting Beta-2 AgonistAsthmaSCE Respiratory

A 44-year-old woman with objectively confirmed asthma is reviewed after 16 weeks of moderate-dose maintenance and reliever therapy (MART) using DuoResp Spiromax 160/4.5 micrograms, two inhalations twice daily and one inhalation as needed. Electronic monitoring confirms 96% adherence, inhaler technique is satisfactory and relevant occupational and environmental exposures have been excluded. She continues to use reliever doses on 4 days each week and wakes with asthma once weekly. Seven months ago, she required prednisolone for an asthma exacerbation. Post-bronchodilator FEV1 is 72% predicted. FeNO is 13 ppb and blood eosinophils are 90 cells/µL; both results have been replicated during clinical stability, more than 10 weeks after systemic corticosteroid exposure. A previous adherent 12-week trial of montelukast produced no clinical benefit and was stopped. Which treatment plan is most appropriate?

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Correct answer: E — Continue moderate-dose MART and add tiotropium Respimat 5 micrograms once daily for an 8–12-week trial

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

Her asthma remains uncontrolled despite an adequate trial of moderate-dose ICS/formoterol MART, objectively verified adherence and satisfactory technique. The low FeNO and repeatedly low eosinophil count direct management away from the biomarker-triggered specialist-referral branch of the BTS/NICE/SIGN pathway. NICE instead recommends an 8–12-week trial of an LTRA or LAMA added to moderate-dose MART. Because a valid montelukast trial was ineffective, tiotropium is the appropriate alternative. She also meets the licensed adult tiotropium criteria: severe asthma, an exacerbation within the preceding year, and background ICS equivalent to at least 800 micrograms budesonide daily plus another controller. B unnecessarily removes the ICS/formoterol anti-inflammatory reliever component; the LAMA is added to MART rather than requiring substitution with SABA. C abandons the recommended MART sequence and escalates corticosteroid exposure without first testing the indicated non-steroid add-on. D repeats a properly conducted treatment trial that produced no benefit. E is premature because neither type 2 biomarker is raised and the recommended LAMA trial has not yet occurred; specialist referral becomes appropriate if relevant biomarkers are raised or control remains inadequate after the recommended treatment sequence.

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 Spiriva Respimat 2.5 microgram inhalation solution — Summary of Product Characteristics (Text revised December 2024) — https://www.medicines.org.uk/emc/product/407/smpc