Asthma Treatment Algorithm
Please note: This algorithm includes the most cost-effective formulary product. Alternative formulary
choices are included on the following page
STEP 1
Mild Intermittent
Asthma
STEP 2
Regular
preventer
therapy
Inhaled short acting beta agonist PRN
 Salbutamol mdi 100mcg/metered inhalation
2 Puffs when required
Add inhaled steroid 200-800mcg per day (BDP equiv/day).
 Clenil 100mcg 2 puffs twice daily
Prescribe beclometasone by brand due to differences in
bioavailability
STEP 3
Initial add-on
therapy
Add long acting beta agonist (LABA)*
Prescribe combination inhalers to aid compliance in line with NICE guidelines.
Preparation with lowest acquisition cost:
 Flutiform (fluticasone / formoterol) MDI 2 puffs twice daily (50mcg/5mcg), 1 puff twice
daily (125mcg/5mcg)
*Points to consider when
prescribing LABAs:
 Always prescribe LABA with
ICS and only when ICS
alone is not controlling
symptoms
 LABA should not be initiated
in patients with rapidly
deteriorating asthma
 Review LABA regularly,
prescribe lowest effective
dose and stop if there is no
benefit
Please ensure the patient can
use their inhaler. It is important
to check inhaler technique on a
regular basis.
Consider step down at each annual review if patient is well controlled.
It may be suitable to consider a switch at an annual review for patients taking other
combined ICS.
Good
response
Continue
with LABA
and ICS
and review
regularly
 Do not prescribe LABA for
the relief of exercise-induced
asthma symptoms in the
absence of regular ICS
 Prescribe combination
inhalers when appropriate to
aid compliance in line with
NICE guidance.4
Some
benefit
No benefit/
response
Continue LABA
Increase ICS to
800mcg per day
(BDP equiv/day)
(see next page for
options)
Stop LABA
Increase ICS to
800mcg per day
(BDP equiv/day)
(see next page
for options)
Control
inadequate
Consider trial of:
Leukotriene receptor antagonist or SR
theophylline (prescribe theophylline by brand –
Neulin, Slo-phyllin or Uniphyllin
Control inadequate
STEP 4
Persistent poor
control
Consider trial of:
 Increasing inhaled corticosteroid up to 2000mcg/day (BDP equiv/day)
 Add in 4th drug e.g. leukotriene receptor antagonist, SR theophylline (prescribe by
brand), oral beta agonist.
Control
inadequate
Before progressing to Step 5 patients should be referred to a specialist
STEP 5
Continuous or
frequent use of
oral steroids

Use daily steroid tablet in lowest dose providing adequate control
Maintain a high dose inhaled steroid at 2000mcg/day (BDP equiv/day)

Consider other treatments (specialist only) to minimise the use of steroid tablets (e.g
Omalizumab, immunosuppressants)
Products are listed according to acquisition cost
Most
costeffective
STEP 1
STEP 2
400-500mcg
BDP equiv./day
Salbutamol mdi
100mcg
2 puffs prn
£0.45
Salbutamol
Accuhaler
200mcg
1 puff prn
£1.50
Salbutamol
Easibreathe
100mcg
2 puffs prn
£1.89
Terbutaline
Turbohaler
500mcg
1 puff prn
£2.08
Cost based on
one dose per day
for 30 days
treatment
Clenil 100mcg mdi
2 puffs bd
£4.45
Qvar 50mcg
Easibreathe
2 puffs bd
£4.64
Qvar 50mcg
2 puffs bd
£4.72
Fluticasone 50mcg
Evohaler
2 puffs bd
£5.44
Budesonide Turbohaler
100mcg
2 puffs bd
£7.10
Budesonide Turbohaler
200mcg
1 puff bd
£7.10
Fluticasone 125mcg
Evohaler
1 puff bd
£10.63
STEP 3
STEP 4
LABA
Clenil 200mcg MDI 2 puffs bd £9.70
Formoterol 12mcg DPI 1 puff bd £12.40
Qvar 100mcg Easibreathe 2 puffs bd £10.17
Salmeterol 25mcg MDI 2 puffs bd £29.26
Qvar 100mcg MDI 2 puffs bd £10.33
Salmeterol 50mcg Accuhaler 1 puff bd £29.26
Beclometasone 250mcg MDI 2 puffs bd £9.77
ICS/LABA combination
Budesonide 200mcg Turbohaler 2 puffs bd £14.21
400-500mcg BDP equiv./day
Budesonide 400mcg Turbohaler 1 puff bd £16.63
Flutiform 125/5 MDI (fluticasone / formoterol)
1 puff twice daily £14.00
Fluticasone 250mcg MDI 1 puff bd £18.07
Flutiform 50/5 MDI (fluticasone / formoterol)
2 puffs bd £14.40
Fluticasone 500mcg Accuhaler 1 puff bd £36.14
Fostair 100/6 MDI (beclometasone / formoterol) 1
puff bd £14.66
Fluticasone 125mcg MDI 2 puffs bd £21.26
ICS/LABA combination
1000mcg BDP equiv./day
DuoResp Spiromax (budesonide 160mcg /
formoterol 4.5mcg)* 1 puff bd £14.98
Flutiform 250/10 MDI (fluticasone / formoterol) 1 puff
bd £22.78
Seretide 100 Accuhaler (fluticasone 100mcg /
salmeterol 50mcg) 1 puff bd £18.00
Sirdupla 125 MDI (fluticasone 125mcg / salmeterol
25mcg) 2 puffs bd £26.25 ***
Seretide 50 Evohaler (fluticasone 50mcg /
salmeterol 25mcg) 2 puffs bd £18.00
Flutiform 125/5 MDI (fluticasone / formoterol) 2 puffs
bd £28.00
Symbicort 200/6 Turbohaler (budesonide /
formoterol) 1 puff bd £19.00
Fostair 100/6 MDI (beclometasone / formoterol) 2
puffs bd £29.32
Symbicort 100/6 Turbohaler (budesonide /
formoterol) 2 puffs bd £33.00
Seretide 250 Accuhaler (fluticasone 250mcg /
salmeterol 50mcg) 1 puff bd £35.00
2000mcg BDP
equiv./day
Seretide 500
Accuhaler
(fluticasone 500mcg /
salmeterol 50mcg)
1 puff bd
£40.92
Sirdupla 250 MDI
(fluticasone 250mcg /
salmeterol 25mcg) 2
puffs bd £44.61****
Flutiform 250/10 MDI
(fluticasone /
formoterol)
2 puffs bd
£45.56
Seretide 250 evohaler
MDI (fluticasone
250mcg / salmeterol
25mcg)
2 puffs bd
£59.48
800mcg BDP equiv./day
DuoResp Spiromax (budesonide 160mcg /
formoterol 4.5mcg)* 2 puffs bd £29.97
DuoResp Spiromax (budesonide 320mcg /
formoterol 9mcg)** 1 puff bd £29.97
Least
costeffective
STEP 5
Symbicort 200/6 Turbohaler (budesonide /
formoterol) 2 puffs bd £38.00
Symbicort 400/12 Turbohaler (budesonide /
formoterol) 1 puff bd £38.00
Costs based on 30 days treatment (Drug Tariff Sept 2015 and eBNF Sept 2015)
Seretide 125 Evohaler (fluticasone 125mcg /
salmeterol 25mcg) 2 puffs bd £35.00
1600mcg BDP equiv./day
DuoResp Spiromax (budesonide 320mcg /
formoterol 9mcg)** 2 puff bd £59.94
Symbicort 400/12 Turbohaler (budesonide /
formoterol) 2 puffs bd £76.00
*Equivalent to Symbicort 200/6
**Equivalent to Symbicort 400/12
***Equivalent to Seretide 125 Evohaler
****Equivalent to Seretide 250 Evohaler