BCCG Formulary Choices: Asthma Treatment Guidelines for Adults and children over 12 years
Key Points:
Ensure patient has a personal asthma action plan which includes warning signs of poor asthma control and
what to do during an attack
 Start treatment at the step most appropriate to initial severity of their asthma.
 Patients should receive training for each device prescribed, and be able to demonstrate satisfactory technique.
Try to limit number of different devices a patient has
 Check concordance and reconsider diagnosis if response to treatment is unexpectedly poor.
 Perform yearly asthma review
 Consider a spacer device for patients prescribed a metered dose inhaler (MDI) who are:
o Having difficulty co-ordinating actuation and inhalation.
o Receiving high doses of inhaled corticosteroid (ICS) (>800 mcg of beclometasone or equivalent daily).
Indicators associated with increased risk of death (from NRAD report)







Recent hospitalisation
Previous severe attacks
Non-attenders for planned review
LABA monotherapy without ICS
Using more than 12 reliever inhalers per year
Using less than 12 preventer inhalers per year
Step 1:
Inhaled SABA prn
Salbutamol MDI 100mcg / dose inhaler CFC free 1-2 puffs PRN
Stepping Up?
Think T.T.T.



Adherence with
Therapy- Do they
use it?
Technique- Can
they use it?
Trigger factors
Refer to Community
pharmacist for New
Medicine Service or
Medicine Use
Review.
Step 2:
Add in regular ICS [BDP 400mcg/day]
Clenil Modulite® (beclometasone) 100 microgram per dose + / - spacer 2 puffs twice daily
Can decrease dose if controlled

Step 3 - initial:
Replace with LABA/ICS combination
Fostair® CFC free inhaler (beclometasone / formoterol) 100 microgram / 6 microgram
+/- spacer 1 puff twice daily [BDP 500 mcg/day]

(Child 12-17 years) Symbicort 200/6 Turbohaler® [BDP 400-800 mcg / day]
1 or 2 puffs twice daily reduced to 1 puff once daily if control maintained.
Can decrease dose if controlled
Step 3 – follow on:

Benefit from LABA/ICS but inadequate response, increase
ICS dose in combination inhaler
Fostair® CFC free inhaler (beclometasone / formoterol) 100
microgram / 6 microgram +/- spacer 2 puffs twice daily [BDP
1000mcg/day]

If no response to LABA/ICS, review diagnosis. Stop LABA
and initiate higher dose ICS [BDP 800mcg/day]
Clenil Modulite® (beclometasone) 200 microgram per dose + /
- spacer 2 puffs twice daily

If asthma still not controlled add either a leukotriene receptor
antagonist (LTRA) (Montelukast 10mg tablets in the evening;
(Child 12 – 15 years- Montelukast 5mg tablets or chewable
tablets 5mg in the evening) or SR theophylline (Phyllocontin
Continus® tablets 225mg twice daily for one week then
increased to 2 tablets twice daily if necessary.)
Maintenance and reliever therapy
 Consider only for stable patients
on step 3 with a personal asthma
plan able to manage their own
treatment.
 Caution – can become
expensive and needs closer
monitoring of patient /
prescriptions. Only consider for
patients using < 2 SABA inhalers
per year.
 Use Fostair® CFC free inhaler
(beclometasone / formoterol)
100 microgram / 6 microgram
+/- spacer 1 puff twice daily; for
the relief of symptoms 1 puff
as needed; max. 8 puffs daily.
Step 4:
Consider trial of:
 Increasing ICS dose up to BDP 2000mcg/day – Clenil Modulite® (beclometasone) 200
microgram per dose +/- spacer up to 4 puffs twice daily or Clenil Modulite®
(beclometasone) 250 micrograms per dose +/- spacer up to 4 puffs twice daily . If
previously on ICS/LABA add in formoterol Easyhaler® 12 mcg/dose 1 puff twice daily.
 Or addition of either a LTRA (Montelukast 10mg tablets in the evening; (Child 12 – 15
years- Montelukast 5mg tablets or chewable tablets 5mg in the evening) or SR
theophylline (Phyllocontin Continus® tablets 225mg twice daily for one week then
increase to 2 tablets twice daily if necessary.)
If trial of an add-on treatment is ineffective seek specialist advice before proceeding.
Stepping Down?



Reduce ICS dose
slowly
Aim to use the
lowest effective ICS
dose
Consider a
treatment review
every 12 weeks
Step 5:
Refer to respiratory specialist
Flow chart based on recommendations from the British Thoracic Society and Scottish Intercollegiate Guidelines Network
BCCG Formulary Choices: Asthma Treatment Guidelines for Children aged 5 to 12 years
Key Points:
Ensure patient has a personal asthma action plan which includes warning signs of poor asthma control and
what to do during an attack
 Start treatment at the step most appropriate to initial severity of their asthma.
 Patients should receive training for each device prescribed, and be able to demonstrate satisfactory technique.
Try to limit number of different devices a patient has. Metered dose inhaler (MDI) with a spacer device is the
preferred option for children
 Check concordance and reconsider diagnosis if response to treatment is unexpectedly poor.
 Perform yearly asthma review
 Regularly review the use of high dose inhaled corticosteroids in children
Indicators associated with increased risk of death (from NRAD report)







Recent hospitalisation
Previous severe attacks
Non-attenders for planned review
LABA monotherapy without ICS
Using more than 12 reliever inhalers per year
Using less than 12 preventer inhalers per year
Stepping Up?
Think T.T.T.



Step 1:
Inhaled SABA prn up to once daily
Salbutamol MDI 100mcg / dose inhaler CFC free + / - spacer 1-2 puffs PRN
Adherence
with TherapyDo they use it?
TechniqueCan they use
it?
Trigger factors
Refer to
Community
pharmacist for
New Medicine
Service or
Medicine Use
Review.


Step 2:
Add in regular ICS
Clenil Modulite® (beclometasone) 100 microgram per dose + spacer 1 puff twice daily
[BDP 200mcg/day]
Can decrease dose if controlled consider alternative preventer if ICS cannot be used
i.e. Leukotriene receptor antagonist (LRTA) (5 years – Montelukast chewable tablets
4mg in the evening; 6-12 years Montelukast chewable tablets 5mg in the evening.)
Step 3 - initial:
Replace with LABA/ICS combination
Symbicort 100/6 Turbohaler® (6-12 years 2 puffs twice daily) [BDP 400 mcg / day]
Step 3 – follow on:
If no response to LABA/ICS, review diagnosis. Discontinue LABA and continue ICS
Clenil Modulite® (beclometasone) 100 microgram per dose + spacer 2 puffs twice daily [BDP
400mcg/day]
If asthma still not controlled add either LTRA (5 years – Montelukast chewable tablets 4mg in the
evening; 6-12 years Montelukast chewable tablets 5mg in the evening) or SR theophylline
(Phyllocontin Continus® tablets 225mg – body weight over 40kg initially one tablet twice daily
increased after 1 week to 2 tablets twice daily according to plasma theophylline concentrations)
Step 4:
Consider trial of:
 Increasing ICS dose up to BDP 800 mcg/day – Clenil Modulite®
(beclometasone) 100 microgram per dose + spacer up to 4 puffs twice daily
plus Formoterol Easyhaler® 1 puff (up to 2 puffs) twice daily if LABA of
benefit.
 Consider risk vs benefit of using off label combination ICS/LABA in children Symbicort 200/6 Turbohaler® (6-12 years -up to 2 puffs twice daily) [up to
BDP 800mcg / day]
 Or addition of either a LTRA (5 years – Montelukast chewable tablets 4mg in the
evening; 6-12 years Montelukast chewable tablets 5mg in the evening) or SR
theophylline (Phyllocontin Continus® tablets 225mg – body weight over 40kg
initially one tablet twice daily increased after 1 week to 2 tablets twice daily
according to plasma theophylline concentrations)
 If trial of an add-on treatment is ineffective seek specialist advice before
proceeding.
Stepping
Down?



Reduce ICS
dose slowly
Aim to use the
lowest effective
ICS dose
Consider a
treatment
review every
12 weeks
Step 5:
Refer to respiratory specialist
Flow chart based on recommendations from the British Thoracic Society and Scottish Intercollegiate Guidelines Network
Flow chart based on recommendations from the British Thoracic Society and Scottish Intercollegiate Guidelines Network