Initial assessment and diagnosis: Asthma diagnosis requires a suggestive clinical history (wheeze, cough, breathlessness, chest tightness, symptom variability) supported by objective tests; diagnosis should not be confirmed without both NICE NG245. Physical examination may identify wheeze but a normal exam does not exclude asthma NICE NG245.
Initial treatment: For people aged 12 and over with newly diagnosed asthma, offer a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as needed for symptom relief (anti-inflammatory reliever [AIR] therapy) NICE CKS. If symptoms are frequent or severe, offer low-dose maintenance and reliever therapy (MART) with ICS/formoterol NICE CKS. For children under 5, start with low-dose ICS for 8–12 weeks as empirical treatment, with specialist referral if diagnosis is uncertain or asthma is uncontrolled NICE CKS.
Self-management and education: Provide advice on self-care, avoidance of triggers, smoking cessation, weight management, regular physical activity, stress management, and ensure vaccinations are up to date NICE CKS. A personalised asthma action plan should be provided and reviewed regularly NICE CKS,NICE NG245.
Monitoring: Review asthma control at least annually and after exacerbations, using symptom questionnaires and clinical assessment; routine peak expiratory flow monitoring is not recommended unless personalised NICE NG245. Fractional exhaled nitric oxide (FeNO) monitoring may be considered in adults NICE NG245.
Stepping up and down treatment: Step up treatment if control is suboptimal, considering MART or adding leukotriene receptor antagonists (LTRA) in children if MART is not suitable NICE CKS,NICE NG245. Step down treatment after 8–12 weeks of good control, maintaining the minimum effective ICS dose, with instructions on how to restart if symptoms worsen NICE CKS.
Specialist referral: Refer to asthma specialists if diagnosis is uncertain, asthma is uncontrolled despite treatment, or occupational asthma is suspected NICE NG245.
Pregnancy: Continue ICS-containing treatment during pregnancy to reduce risk of exacerbations and adverse perinatal outcomes NICE CKS.
Key References
- CKS - Asthma
- NG245 - Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN)
- Theophylline SmPC
- Formoterol fumarate SmPC
- Reslizumab SmPC
- Mepolizumab SmPC
- Salmeterol SmPC
- Budesonide with formoterol SmPC
- Tiotropium SmPC
- Ciclesonide SmPC
- NG115 - Chronic obstructive pulmonary disease in over 16s: diagnosis and management