Compliance
Compliance with treatment is important and should be checked regularly, especially if symptom control is poor or treatment is about to be increased (D)
Inhaled short acting b2 agonists
Inhaled short acting b2 agonists should be used on an "as required" basis to relieve symptoms (B)
They should be used before exercise in patients who have exercise-induced bronchospasm (A)
As there is no good evidence of clinically important differences between different inhaled short acting b2 agonists, patients should be treated with the cheapest preparation that they can effectively use (D)
Long acting inhaled b2 agonists
In most patients treated with inhaled long acting b2 agonists symptoms will be satisfactorily controlled on 50 mg salmeterol twice daily or 12 mg formoterol twice daily. If these drugs are used in higher doses attention must be paid to side effects (A)
If patients’ symptoms are not controlled on up to 1000 mg beclometasone daily (or equivalent) then regular inhaled long acting b2 agonists should be added to their treatment (A)
Treatment with an inhaled short acting b2 agonist should be continued as required (B)
Inhaled long acting b2 agonists should be considered if overnight relief is required (A)
Inhaled long acting b2 agonists should be used in preference to sodium cromoglycate or oral bronchodilators (A)
As there is no good evidence of clinically important differences between different inhaled long acting b2 agonists, patients should be treated with the cheapest preparation that they can effectively use (D)
Inhaled corticosteroids
Patients requiring more than two to three doses a day of inhaled short acting b2 agonists should be treated with inhaled corticosteroids (A)
Inhaled corticosteroids should usually be used twice daily (rather than once or four times daily) (B)
If symptoms are not controlled on twice daily dosing and there is concern about the total daily dose then dose frequency can be increased to four times daily but at the same total daily dose (A)
If patients’ symptoms are not controlled on up to 1000 mg beclometasone daily (or equivalent) regular inhaled long acting b2 agonists should be added (A)
If symptoms are not controlled on standard doses (up to a daily equivalent of 1000 mg beclometasone) plus the addition of regular inhaled long acting b2 agonists, higher doses of inhaled corticosteroids should be used up to a daily equivalent of 2000 mg beclometasone (D)
A one to three month period of stability should be shown before slow stepwise reduction of inhaled corticosteroids is undertaken, decreasing the dose of inhaled corticosteroid by about 25-50% at each step (D)
As there is no good evidence of clinically important differences between different inhaled corticosteroids, patients should be treated with the cheapest inhaled corticosteroid that they can effectively use and which controls their symptoms (D)
Other anti-inflammatory agents
Nedocromil or sodium cromoglycate may be useful in occasional patients as an adjunct to inhaled steroids or as an alternative in those patients who cannot tolerate or do not want to take inhaled corticosteroids. They should be considered as a second line treatment to inhaled corticosteroids (B)
Leukotriene antagonists
The appropriate therapeutic position of leukotriene antagonists is not clear, and currently they should be considered among the alternative drugs to use after inhaled short and long acting b2 agonists and corticosteroids(A)
Drug delivery devices
Healthcare professionals who advise patients should use the cheapest drug delivery device that the patient can use and comply with effectively (D)
Patients should initially be treated with a metered dose inhaler (D)
If patients cannot coordinate the activation of a metered dose inhaler then a large volume spacer device should be added (C)
Large volume spacer devices should be used with inhaled drugs when the aim is to deal with problems coordinating the use of a metered dose inhaler or to increase the effectiveness of inhaled drugs without increasing dose. Additionally they should be used with high dose inhaled corticosteroids to decrease oral candidiasis (A)
Patients who cannot use a metered dose inhaler plus large volume spacer should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with (D)
Patients who find a metered dose inhaler plus large volume spacer difficult to carry round during the day should be treated with the cheapest powder or automatic aerosol inhaler that they can comply with for daytime use (D)
In acute settings large volume spacer devices are an effective alternative to nebulisers for delivering high dose bronchodilators (A)
Inhaler technique
Healthcare professionals should ensure that patients can use their inhalers adequately (D)
Inhaler technique should be rechecked whenever control is in doubt (D)
Oral bronchodilators
Oral bronchodilators should be considered as second line treatment to the use of inhaled bronchodilators and corticosteroids together(A)
Chronic asthma: sequencing drugs
The trigger to increasing treatment at all stages is if the short acting inhaled b2 agonist is being used more than two to three times daily or symptom control is not good (the British Thoracic Society Guidelines define good control as minimal chronic symptoms (ideally none); minimal (infrequent) exacerbations; minimal need for relieving bronchodilators; no limitations on activities) (D)
Compliance should be checked before any treatment increase (D)
A one to three month period of stability should be shown before slow stepwise reduction in treatment is undertaken, decreasing the dose of inhaled corticosteroid by about 25-50% at each step (D)
Non-drug treatment
Patients should not be treated solely with acupuncture (A), yoga (A), or homoeopathy (A)
Exacerbations of asthma
Patients with an exacerbation of asthma should be treated with oral corticosteroids; there is currently no good evidence to suggest the use of high dose inhaled corticosteroids as an alternative (A)
Prednisolone should be given at dosages of 30-40 mg daily and continued until the episode has resolved, symptoms are controlled, and lung function has returned to previous best levels. While seven days of treatment will often be sufficient, continuation for up to 21 days may be necessary (B)
Use of oral corticosteroids does not need to be tapered; they can be stopped from full dosages. In patients on maintenance oral steroids reduction should be to their pre-exacerbation dose rather than stopping (D)
Depending on the severity of the episode patients may need an inhaled short acting b2 agonist via either a nebuliser or a large volume spacer device (A)
Inhaled treatment should be used in preference to intravenous b2 agonists for the treatment of exacerbations of asthma in primary care (A)
Inhaled treament can be delivered as effectively by spacer as by nebuliser (A)
For patients given inhaled short acting b2 agonist via a spacer device clinicians should consider repeat doses at 30-60 minutes; reassessment of such patients is important (A)
Allergen avoidance and allergen specific immunotherapy
Mite reduction methods should not be routinely recommended (A)
Allergen specific immunotherapy may be appropriate for certain patients but it is not currently a treatment offered in primary care (A)
Smoking and smoking cessation
The current smoking status of all patients should be known (D)
While there is no one strategy that is effective for all patients, strategies should be centred around advice and support from a health professional and nicotine replacement therapy in those who are motivated to quit (A)
Advice and strategies should be tailored to individual circumstances (D)
Patients should avoid passive smoking (D)
Patient education and self management
Patients should be offered education about their condition and its management (A)
Self management education, which involves a written action plan, self monitoring, and regular medical review, should be offered to adults with asthma (B)
The routine home use of peak flow meters for self management is not mandatory (A)
Referral to a chest physician
Referral to a respiratory physician is appropriate for:
· Patients with possible occupational asthma
· Patients who present a problem in management (D)
Patients who are being considered by their general practitioners for long term oral corticosteroids or home use of a nebuliser should be referred to a respiratory physician for assessment (D)
Patients who have recently been discharged from hospital should have their treatment reviewed; this does not need hospital review if the primary healthcare professional possesses the relevant skills and resources (D)
Patient preference should be accommodated in the decision to refer (D)
Primary healthcare professionals should be aware of the range of skills and facilities available within their practice and should, when appropriate, refer within the practice (D)