Asthma: Management in Adults

Key points

• BTS/NICE/SIGN NG245 (Nov 2024) replaced the previous pathways. The headline change: SABA MONOTHERAPY IS NO LONGER RECOMMENDED — never prescribe a short-acting beta-2 agonist without a concomitant inhaled corticosteroid (reinforced by an MHRA Drug Safety Update in April 2025).
• Diagnosis requires objective testing, not clinical suspicion alone: FeNO ≥ 40 ppb AND spirometry showing obstruction with bronchodilator reversibility (FEV1 improvement > 12% and > 200 ml) · if one test is negative but suspicion is high, use a peak flow diary (variability > 20%) or a monitored treatment trial.
• FIRST-LINE (aged 12 and over): as-needed low-dose ICS/formoterol — anti-inflammatory reliever (AIR) therapy · taken only when symptoms occur, with no regular maintenance inhaler.
• If symptoms are frequent, or the patient presents with a severe exacerbation: start low-dose MART (maintenance and reliever therapy) — one ICS/formoterol inhaler used both regularly and for relief · people on MART do not normally need a SABA at all.
• Escalation: low-dose MART → moderate-dose MART → trial of an LTRA and/or a LAMA → refer to a specialist if still uncontrolled · review response 8-12 weeks after any change · montelukast carries an MHRA warning about neuropsychiatric reactions.
• Switching legacy patients: SABA alone → change to as-needed ICS/formoterol (AIR) regardless of control · low-dose ICS or ICS/LABA with as-needed SABA → consider low-dose MART · moderate-dose ICS or ICS/LABA → consider moderate-dose MART.
• Acute exacerbation: prednisolone 40-50 mg daily for 5 days, with no taper needed if the course is under 3 weeks · if there is no improvement within 24-48 hours, admit.

Decision points in this pathway

• Symptoms frequent, or presenting with a severe exacerbation?
• Still uncontrolled on low-dose MART?
• Still uncontrolled on moderate-dose MART?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.