British Guideline on the Management of
Asthma
BTS/SIGN British Guideline on the Management of Asthma, May 2008
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Introduction
Diagnosis
Non-pharmacological management
Pharmacological management
Inhaler devices
Management of acute asthma
Special situations
Organisation and delivery of care,
and audit
• Patient education and selfmanagement
• Development of the guideline
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Asthma control
BTS/SIGN British Guideline on the Management of Asthma, May 2008
• Aim is for asthma control:
 no daytime symptoms
 no night time awakening due to asthma
 no need for rescue medication
 no exacerbations
 no limitations on activity including exercise
 normal lung function
• Before moving up to the next step:
 Check compliance
 Check inhaler technique
 Eliminate trigger factors
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At any stage, step down therapy once asthma is
controlled
Measuring clinical outcomes
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Ask the patient three key questions:
In the last week (or month):
1. have you had difficulty sleeping because of your
asthma symptoms (including cough)?
2. have you had your usual asthma symptoms
during the day (cough, wheeze, chest tightness
or breathlessness)?
3. has your asthma interfered with your usual
activities (e.g. housework, work/school etc.)?
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Stepwise management of asthma in adults
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Step 5: Continuous or frequent
use of oral steroids
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Stepwise management of asthma in adults
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Step 1: Mild intermittent asthma
Inhaled short acting ß2 agonist as required
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Step 2: Regular preventer therapy
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Inhaled steroids are the most effective preventer drug for adults and
children for achieving overall treatment goals
Inhaled steroids should be prescribed for patients:
With exacerbation of asthma in the last 2 years
Using inhaled beta2 agonists three times a week or more
Symptomatic three times a week or more
Waking one night a week or more
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Start patients at inhaled steroid dose appropriate to disease severity (e.g.
adults: 400 micrograms per day; children 5-12 years: 200 micrograms per day;
children under 5 years: higher doses may be required to ensure consistent drug
delivery)
Use lowest dose at which effective control of asthma is maintained
Monitor children’s height on a regular basis
In children on inhaled steroids with decreased consciousness, check blood
glucose levels urgently and consider IM hydrocortisone
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In adults doubling the dose of inhaled steroids at the time of exacerbation is of
unproven value
Stepwise management of asthma in adults
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Step 3: Add-on therapies
1. Add inhaled long-acting ß2 agonist (LABA)
2. Assess control of asthma:
• good response to LABA – continue LABA
• benefit from LABA but control still inadequate – continue LABA and
increase inhaled steroid dose to 800 micrograms/day * (if not already on
this dose)
• no response to LABA – stop LABA and increase inhaled steroid to
800 micrograms/day *. If control still inadequate, institute trial of other
therapies
(e.g. leukotriene receptor antagonist or SR theophylline)
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Current advice from the CHM
www.mhra.gov.uk December 2006, updated February 2007
In the management of chronic asthma, formoterol and
salmeterol should:
– be added only if regular use of standard-dose ICS has failed
to control asthma adequately
– not be initiated in patients with rapidly deteriorating asthma
– be introduced at a low dose and the effect properly
monitored before considering dose increase
– be discontinued in the absence of benefit
– be reviewed as appropriate: stepping down therapy should
be considered when good long-term asthma control has
been achieved
Patients should report any deterioration in symptoms
following initiation of treatment with a LABA
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So where does Symbicort SMART® fit in the
management of asthma?
BTS/SIGN British Guideline on the Management of Asthma, May 2008
• In adult patients at step 3, who are poorly controlled:
– The use of budesonide/formoterol in a single inhaler
(Symbicort SMART®) as rescue medication instead of
a short-acting β2 agonist, in addition to its regular use
as a controller treatment, has been shown to be an
effective treatment option
– Before instituting this management, careful patient
education is required
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Stepwise management of asthma in adults
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Step 4: Persistent poor control
Consider trials of:
• increasing inhaled steroid up to 2000mcg/day *
• addition of fourth drug (e.g. leukotriene receptor
antagonist, SR theophylline, ß2 agonist tablet)
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Stepwise management of asthma in adults
BTS/SIGN British Guideline on the Management of Asthma, May 2008
Step 5: Continuous or frequent use of oral steroids
Use daily steroid tablet in lowest dose providing adequate control
Maintain high dose inhaled steroid at 2000mcg/day *
Consider other treatments to minimise the use of steroid tablets
Refer patient for specialist care
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Asthma – treatment summary
• BTS/SIGN guidance is the basis for treatment
• Use the RCP three questions to help assess control,
not (just) PEFR and FEV1
• Start at step appropriate for patient’s asthma, and
step down when control achieved and patient is
stable
• Safety issues and concerns regarding high-dose
inhaled steroids and long-acting beta2-agonists
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