Section 3:

Pharmacological therapy
Reliever therapy

According to the BTS/SIGN asthma guideline, adults and children with a diagnosis of asthma should be prescribed a short acting bronchodilator to relieve symptoms. For those with infrequent, short-lived wheeze, occasional use of reliever therapy may be the only treatment needed. Short-acting bronchodilators include:

  • Inhaled short-acting β2 agonists (SABA)
  • Inhaled ipratropium bromide
  • Theophyllines

Good asthma control is associated with little or no need for SABA, which should only be used as required for the relief of symptoms.1

Over-reliance on SABA can cause tolerance and rebound effects.2

Anyone prescribed more than one SABA inhaler device a month should be identified and their asthma should be assessed urgently, and steps taken to improve asthma control if this is poor.1

Preventer therapy

Anyone using inhaled SABA or who is symptomatic more than three times a week, or waking one night a week because of asthma symptoms should be prescribed an inhaled corticosteroid (ICS).1 ICS are the most effective drugs for the control of symptoms and prevention of attacks in adults and older children.1

The starting dose of ICS for adults is low dose, and for children very low dose. The dose should be adjusted to the lowest dose at which effective control of asthma is maintained. Current and previous smoking reduces the effect of ICS, and doses may need to be increased.1

  • Beclometasone diproprionate (BDP) and budesonide are approximately equivalent in clinical practice,1 although there may be variations with different delivery devices.
  • Fluticasone proprionate provides equal clinical activity to BDP budesonide at half the dosage.1
  • Mometasone appears to provide equal clinical activity to BDP and budesonide at half the dosage.1
  • It is difficult to establish the exact equipotent dose of fluticasone furoate.1

A guide to categorisation of ICS by dose and inhaler device for adults can be found in Table 12 of the BTS/SIGN guideline, and in Table 13 for children, at https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

Side effects of ICS

There is little evidence that low doses of ICS cause any short-term adverse effects in adults apart from local side effects of dysphonia (hoarseness) and oral candidiasis (thrush).1 These side effects can be prevented by:

  • Using a spacer with a metered dose inhaler (MDI)
  • Using a good inhaler technique
  • Rinsing the mouth and spitting out after use.3

In children, medium- or high-dose ICS may cause systemic side effects, including growth failure and adrenal suppression. The growth (height and weight centile) of children with asthma should be monitored annually, and the lowest dose of ICS that maintains asthma control should be used. Children treated with medium- or high-dose ICS should be under the care of a specialist paediatrician.1

Other preventer therapies

Inhaled corticosteroids are the first choice of preventer drug. Other preventer therapies include leukotriene receptor antagonists (LTRA), which can be used in children under 5 years who are unable to take ICS. Sodium cromoglicate, nedocromil sodium and theophyllines have some benefit in adults and children >5 years.1

BTS/SIGN ALGORITHM FOR PHARMACOTHERAPY IN ADULTS

Adapted from BTS/SIGN British Guideline on the management of asthma, 2019

Initial add-on therapy

Some asthma patients may not be adequately controlled with low-dose ICS alone. Before a new drug is added, it is important to check adherence and inhaler technique.1

The first choice as add-on therapy to ICS in adults is an inhaled long acting β2 agonist (LABA), in preference to increasing the dose of ICS. (See algorithm). In children ≥5 years, either LABA or LTRA can be considered.1

A combination inhaler is recommended to ensure that the LABA is not taken without the ICS and to improve adherence.

A single combination inhaler for maintenance and reliever therapy (MART) may be suitable for some patients. MART combines rapid onset of reliever effect with formoterol with ICS, and as the need for a reliever increases, the dose of preventer is also increased.2 However, not all ICS+formoterol preparations are licensed for MART, so it is important to check the summary of product characteristics for the individual product. Patients taking rescue doses of their combination inhaler once a day or on a more regular basis should have their treatment reviewed.1

Combination inhalers should be prescribed and dispensed by brand name.1 All patients whose asthma is not adequately controlled on recommended initial or additional controller therapies should be referred for specialist care.1

Job code: UK/RES-19014c DOP: February 2020

References

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) British Guideline on the Management of Asthma; 24 July 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed February 2020]
  2. Valero A, Olaguibel J, Delgado J. Dilemmas and new paradigms in asthma management. J Investig Allergol Clin Immunol 2019;29(1):15-23
  3. Asthma UK. Preventer inhalers. https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/preventer/#effects [Accessed February 2020]