asthma step up treatment adults

Question 1

adults (17 and over) - REGULAR preventer therapy in pt who present with any one of the following features: using an inhaled short-acting beta2 agonist three times a week or more, symptomatic three times a week or more, or waking at night due to asthma symptoms at least once a week

Answer 1

LOW DOSE ICS AS MAINTENANCE

e.g. Clenil 100 2 puffs BD

Question 2

If asthma in adults (17 and over) is uncontrolled on SABA reliever + low dose ICS maintenance, what is add on treatmeant

Answer 2

LTRA (montelukast 10mg OD at bedtime)
review response in 4-8 weeks

Question 3

If asthma in adults (17 and over) is uncontrolled on low dose ICS + LTRA (montelukast 10mg OD evening) as maintenance, what is the next step

Answer 3

LABA (formoterol, salmeterol) in combination with the ICS should be offered with or without continued LTRA treatment, depending on the response achieved from the LTRA.

Question 4

If asthma remains uncontrolled in adults (17 and over) on low dose ICS + LABA +/- LTRA (depending on response achieved from LTRA) as maintenance, what is the next step

Answer 4

offer to change the ICS and LABA maintenance therapy to a MART regimen, with a low-dose of ICS as maintenance

Question 5

If asthma remains uncontrolled on a MART regimen with a low-dose of ICS as maintenance with or without a LTRA (depending on pt response to LTRA), what is the next step

Answer 5

consider increasing to a moderate-dose of ICS (either continuing a MART regimen, or changing to a fixed-dose regimen of an ICS and a LABA with a short-acting beta2 agonist as reliever therapy)

Question 6

does MART contain LABA or SABA

Answer 6

LABA

Question 7

If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA, consider the following 3 options

(adults 17 and over)

Answer 7

Increasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or
A trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or
Seeking advice from an asthma specialist.

Question 8

if patient is having a high dose ICS as maintenance can this be in MART form

Answer 8

no
should only be offered as part of FIXED dose regimen with SABA as reliever

Question 9

can a LAMA e.g. tiotropium be used in asthma

Answer 9

yes

Question 10

Monoclonal antibodies such as omalizumab, mepolizumab, benralizumab, reslizumab and dupilumab can be considered in …..

Answer 10

certain patients with severe asthma to achieve control and reduce the use of oral corticosteroids; immunosuppressants such as methotrexate [unlicensed] may also be considered as recommended by BTS/SIGN (2019).

Question 11

BTS summarise the treatment

Answer 11

1. SABA
2. low dose ICS
3. • LABA. (fixed dose or as MART)
4. if some benefit from LABA but control is inadequate, continue it and EITHER increase dose of ICS to medium, or all LTRA.
   If no response to LTRA, consider discont and either increasing ICS to medium, or adding LTRA
5. referral for specialist asthma care