A 24-year-old female comes for review. She was diagnosed with asthma two years ago and is currently using a salbutamol inhaler 100mcg prn combined with beclometasone dipropionate inhaler 200mcg bd. Despite this her asthma is not well controlled. On examination her chest is clear and she has a good inhaler technique. What is the most appropriate next step in management?
Increase beclometasone dipropionate to 400mcg bd
Switch steroid to fluticasone propionate
Trial of leukotriene receptor antagonist
Add salmeterol
Add tiotropium
The British Thoracic Society (BTS) recommend adding a long-acting B2 agonist if there is an inadequate response to the addition of inhaled steroid. The inhaled steroid dose should be increased if there is an inadequate response to the long-acting B2 agonist.
In the 2016 BTS guidelines an initial ‘low-dose’ for adults is beclometasone dipropionate 200mcg bd, a common clinical example being Clenil.
Asthma: management in adults
The British Thoracic Society (BTS) updated their asthma guidelines in 2016 resulting in some significant changes in how asthma is diagnosed and managed. In terms of management, some of the key changes include:
the previous numbered steps have been abandoned
all patients should receive an inhaled corticosteroid, right from the point of assessment in patients with suspected asthma
a combined inhaled corticosteroid/long-acting beta agonist (ICS/LABA) is recommended instead of separate inhalers to increase compliance
a long-acting muscarinic antagonist (LAMA) is an options for patient who haven’t responded to a combined ICS/LABA inhaler
In terms of management, the BTS suggest the following approach:
- Start treatment at the level most appropriate to initial severity
- Achieve early control
- Maintain control by increasing treatment as necessary and decreasing treatment when control is good
The previous steps 1-5 of asthma management have been abandoned. Previously ‘Step 1’ of asthma management was the use of a short-acting beta agonist (SABA) as required. This is no longer suggested as the initial first step. Instead, all patients from the ‘diagnosis and assessment’ onwards should use a SABA as required. Having to use a SABA more than 3 times per week is considered a sign that further add-on therapy is needed.
Initial step
It is now recommended that a low-dose inhaled corticosteroid (ICS) is started in all patients with a diagnosis, or suspected diagnosis, of asthma, right from the ‘diagnosis and assessment’ period prior to a formal diagnosis being made. The first step of asthma management is now a low-dose inhaled corticosteroid in combination with a short-acting beta agonist.
Next step.
The a long-acting beta agonist (LABA). This should ideally be in the form of a combination inhaler.
Next step…
If poor control remains the next step depends on the response to the LABA:
no response to LABA - stop LABA and increase dose of ICS to medium-dose
response to LABA - continue LABA and increase ICS to medium-dose. An alternative to this is to continue on the current treatment but consider a trial of a leukotriene receptor antagonist, SR theophylline or a long-acting muscarinic antagonist (LAMA)
Next step…
Consider trials of either:
increasing the ICS to high-dose, OR
the addition of a fourth drug (e.g. a leukotriene receptor antagonist, SR theophylline, a LAMA or an oral beta-agonist tablet)
patient should be referred to specialist care at this point
Next step…
The consideration of regular oral steroids at the lowest dose providing adequate daily control.
2016 British Thoracic Society asthma algorithm for adults