LLR Adult Asthma Guideline (≥18 years)

This guideline is for adults with a confirmed diagnosis of asthma. If asthma is suspected, use the Asthma Diagnosis algorithm available on PRISM. There are 2 options for
treatment once asthma is diagnosed: (1) the flexible regimen, derived from evidence-based recommendations from GINA 2023 (Global Strategy for Asthma Management and
Prevention) and is the preferred LLR pathway or (2) the traditional regimen which involves separate relievers and preventers as per BTS/SIGN and NICE asthma guidelines.
Very few patients will have mild START HERE: Medium dose ICS/LABA combination
asthma symptoms. Start here only if: Low dose ICS and reliever for THEN SEVERE ASTHMA (see notes)
ASTHMA SYMPTOMS ≤ TWICE A majority of patients ASTHMA Consider adding Montelukast 10mg nocte, REFER TO SECONDARY CARE
MONTH SYMPTOMS > TWICE A MONTH +/- Spiriva 2.5mcg Respimat 2 doses OD

ICS/LABA AS NEEDED (ANTI- ICS/LABA MAINTENANCE & RELIEVER MAINTENANCE & RELIEVER THERAPY HIGH dose ICS/LABA combination
INFLAMMATORY RELIEVER [AIR]) THERAPY (MART) (MART)
Dry Fobumix 160/4.5 Easyhaler Dry Fobumix 160/4.5 Easyhaler Dry Fobumix 160/4.5 Easyhaler Dry Fobumix 320/9 Easyhaler
FLEXIBLE REGIMEN

powder 1 dose PRN or powder 1 dose BD plus 1 dose PRN powder 2 doses BD plus 1 dose PRN or powder 2 doses BD* or
Inhaler Fostair 100/6 NEXThaler Inhaler Fostair 100/6 NEXThaler Inhaler Fostair 100/6 NEXThaler Inhaler Fostair 200/6 NEXThaler
(DPI) 1 dose PRN or (DPI) 1 dose BD and 1 dose PRN or (DPI) 2 doses BD and 1 dose PRN or (DPI) 2 doses BD or
First Line Symbicort 200/6 Turbohaler First Line First Line Symbicort 200/6 Turbohaler First Line Symbicort 400/12
Symbicort 200/6 Turbohaler
1 dose PRN 1 dose BD plus 1 dose PRN 2 doses BD plus 1 dose PRN Turbohaler* 2 doses BD
Aerosol Luforbec 100/6 MDI Aerosol Luforbec 100/6 MDI Aerosol Luforbec 100/6 MDI plus
If DPI not 1 dose PRN via EasyChamber If DPI not 1 dose BD plus 1 dose PRN via If DPI not 2 doses BD plus 1 dose PRN via
suitable spacer suitable suitable EasyChamber spacer
Easyhaler Salbutamol 100
EasyChamber spacer
1-2 doses PRN
* prescribe 2 x 60 doses / month
NB: ICS/formoterol as a reliever alone (without
Fostair / Luforbec is licensed for maximum 8 doses/24 hours.
maintenance ICS/formoterol) is licensed only Aerosol Luforbec 200/6 MDI
for Symbicort Turbohaler, but off-licence use Fobumix/Symbicort > 8 doses/24 hours is not normally needed; however up to 12 doses could be used If DPI not 2 doses BD via EasyChamber
for Fobumix Easyhaler, Fostair NEXThaler/ MDI for a limited period. If patients use > 8 doses daily, it is strongly recommended they seek medical suitable spacer
and Luforbec MDI endorsed by RPG # advice. No more than 6 inhalations should be taken on any single occasion.
plus Salamol MDI 100mcg
1-2 doses PRN via EasyChamber
CONFIRM DIAGNOSIS and STEP UP and STEP DOWN TREATMENT ACCORDING TO ASTHMA CONTROL
STEP Up and STEP DOWN spacer
All patients with asthma should be treated REGULAR LOW DOSE ICS/LABA AND SABA REGULAR MEDIUM DOSE ICS/LABA + SABA
with an inhaled corticosteroid (ICS); using Consider changing to MART therapy for all At each review:
Consider changing to MART therapy for all
short-acting bronchodilator (SABA) e.g., Assess symptoms, measure lung function,
patients (see above) patients, THEN consider adding
TRADITIONAL REGIMEN

salbutamol monotherapy is now outdated check and optimise inhaler technique and
and no longer acceptable
Montelukast/Spiriva Respimat (see above) adherence.
Dry Fobumix 160/4.5 Easyhaler
REGULAR LOW DOSE ICS PLUS SABA Dry Fobumix 160/4.5 Easyhaler Adjust therapy by stepping up and down
powder 1 dose BD or powder 2 doses BD or treatment (move across). If patients are using
Dry Budesonide 200 Easyhaler Inhaler Fostair 100/6 NEXThaler 1dose their reliever medicine or experiencing
inhaler Fostair 100/6 NEXThaler 2 doses
powder 1 dose BD or (DPI) BD or Symbicort 200/6 symptoms more than twice a week and/or
First Line
(DPI) BD or
Inhaler Pulmicort 200 Turbohaler Turbohaler 1 dose BD First Line
waking once a week or more, escalate
Symbicort 200/6 Turbohaler treatment by moving across (up) the
(DPI) 1 dose BD plus Easyhaler Salbutamol 100
First Line
2 doses BD plus Salbutamol 100 algorithm. Remember to update the patient’s
plus 1-2 doses PRN Easyhaler 1-2 doses PRN personalised self-action plan accordingly.
Easyhaler Salbutamol 100
Aerosol Luforbec 100/6 MDI
1-2 doses PRN If DPI not 1 dose BD via EasyChamber
Aerosol Luforbec 100/6 MDI 2 doses BD via # Inhaler shelf-life - Fobumix Easyhaler (after
Aerosol Qvar 50 MDI 2 doses BD suitable If DPI not EasyChamber spacer opening the foil wrapping, use within 4 months,
plus suitable
If DPI not via EasyChamber spacer or Qvar plus Luforbec MDI (3 months at room temperature),
Salamol 100mcg MDI 1-2 doses Fostair Nexthaler (after opening the pouch use
suitable 50 Easibreathe 2 doses BD plus Salamol 100mcg MDI 1-2 doses PRN
PRN via EasyChamber spacer within 6 months
Salamol 100 MDI 1-2 doses PRN via EasyChamber spacer
Written by A.Murphy, Jan 2024 on behalf of LLR Respiratory
Prescribing Group (RPG). Review date Jan2025
 ASTHMA INHALER CHOICE FORMULARY GUIDE
FLEXIBLE REGIMEN TRADITIONAL Inhalers – THIINK GREEN see LLR APC Green Inhaler
Guide
Dry powder Fobumix 160/4.5 Budesonide 200 The NHS has set the target of reaching net zero by 2040 for the
Inhaler (DPI) Easyhaler Easyhaler greenhouse gas emissions which it can control (‘NHS Carbon
First Line Footprint’). Inhalers are included in this scope and account for
approximately 13% of the carbon footprint related to delivery of
Pulmicort 200 care. To reduce the carbon footprint of inhaler prescribing:
or
Fostair 100/6
Turbohaler  Optimise asthma care following national guidelines.
NEXThaler  Offer dry powder inhalers (DPI) or soft mist inhalers as first
choice where clinically appropriate.
Fobumix 160/4.5 +
or  Check and optimise inhaler technique. Use How to use your
320/9 Easyhaler
Symbicort 200/6 inhaler | Asthma UK videos.
Turbohaler  Ask patients to return all used or unwanted inhalers to
community pharmacies for disposal by incineration or re-
Fostair 100/6 + 200/6
cycling.
NEXThaler
7 steps to Optimise Inhaler Technique
Symbicort 200/6 + 1 Prepare the inhaler device.
400/12 Turbohaler
2 Prepare or load the dose.
Easyhaler Salbutamol 3 Breathe out gently as far as is comfortable, not into the
100 inhaler.
4 Tilt the chin up slightly and put the mouthpiece in your
Aerosol Luforbec 100/6 MDI Qvar 50 MDI mouth and close your lips around it.
If DPI not suitable via spacer device via spacer device
Easychamber EasyChamber 5 Breathe in: for Aerosol (e.g., pMDI, (SMI) - Slowly and
steadily, /and for Dry Powder Inhaler (DPI) - Quickly and
deeply.
Qvar 50 Easibreathe
6 Remove the inhaler from your mouth and hold your
breath for up to 10 seconds or for as long as possible.
Luforbec 100/6 + 7 Wait a few seconds then repeat steps 1-6 for a second
FLEXIBLE ICS/LABA PRESCRIBING
 Most of the evidence for MART and AIR is with DPI inhalers –
200/6 MDI dose, if needed. Close inhaler/replace lid as appropriate.
recommend to prescribe first line via spacer device
 If MDI prescribed a spacer device must be provided/used Easychamber ADDITIONAL MEDICINES
 MART: at initiation prescribe 2 inhalers – one to use BD and one
PRN Salamol 100 MDI
 Ensure prescribing templates allow patients to order PRN Spiriva 2.5mcg Respimat
via spacer device Limited benefit in asthma patients with normal lung
ICS/LABA. Monitor prescription and review if >3 extra/year EasyChamber function
 Use read codes for single inhaler maintenance and reliever therapy
 FURTHER INFORMATION Prescribing Tips KEY: SABA (Short-acting beta-agonist); ICS (Inhaled corticosteroid), LABA (Long-acting
beta –agonist), MDI (metered dose inhaler), DPI = dry powder inhaler
AIM OF TREATMENT
 Review patients regularly, frequency depending on control (at least annually).
To control the disease with minimal side-effects. Asthma control is defined as:
 No daytime symptoms  Use the lowest effective ICS (+/-LABA) doses to achieve and maintain control – step down.
 No night time awakening due to asthma  Remember Qvar/Luforbec (extra fine particle beclometasone) are 2.5 times as potent as Clenil (non-
 No need for rescue medications extra-fine beclometasone).
 No exacerbations  High doses of ICS may cause long term harm. If the patient is well controlled and stable, then consider
 No limitations on activity including exercise reducing the dose.
 Normal lung function
 When using ICS consider total daily steroid load (including intranasal, topical, and oral steroids). Issue
Use ACT to assess and monitor asthma control - In the past 4 weeks a steroid emergency card to patients as per guidance.
1. How much of the time did your asthma keep you from getting as much done at  A spacer device is mandatory when using a metered dose inhaler (MDI) for all ages.
work, school or home?  All people should receive education and a written personalised Asthma Action Plans your-asthma-
1. 2 3 4 5 plan-a4-trifold-digital-july22.pdf {available in GP clinical systems, access through Asthma Checklist
All of the time Most of the time Some of the time A little of the time None of the time
2. How often have you had shortness of breath?
Template).
 Check inhaler technique and adherence to medicine regimen (check prescription issues) at each
1. 2. 3. 4 5.
More than Once a day 3 to 6 times a day Once or twice a Not at all appointment and/or before any change in treatment. Consider referring patients to the community
once a day week pharmacist for a New Medicine Service review.
3. How often did your asthma symptoms (wheezing, coughing, shortness of breath,
chest tightness or pain) wake you up at night or earlier than using in the morning?
 Ensure your patient has had the annual flu vaccination, Covid-19 vaccination.
1. 2. 3. 4. 5.  Check for occupational asthma “Does your breathing get better during weekends/holidays?”
4 or more 2 or 3 nights a Once a week Once or twice Not at all  All patients still smoking, should be encouraged to stop, and offered help to do so at every
nights a week week
4. How often have you used your rescue inhaler (such as salbutamol)? opportunity.
1. 2. 3. 4. 5.
3 or more 1 or 2 times per 2 or 3 times per Once a week or Not at all
times a day day week less 2. Primary Care 3. Secondary Care 4. Severe Asthma Service
5. How would you rate your asthma control during the past 4 weeks?
1. 2. 3. 4. 5.  Identification of patients with  Diagnostic confirmation Severe Asthma is currently
Not controlled Poorly controlled Somewhat Well controlled Completely uncontrolled asthma and phenotyping defined by the level of
at all controlled controlled  Diagnostic confirmation  Treatment optimisation treatment intensity, and
 Clinical optimisation  Additional investigations applies to anyone receiving
Asthma symptom control 1. Indicators of Uncontrolled asthma  Review and optimise inhaler as needed high dose ICS/LABA therapy,
is best assessed using a technique and adherence
 Identification and once other co-factors/co-
validated tool = ACT (i) Over previous 12 months (any of):  Review biomarkers: blood morbidities have been
management of co-
questions (but you must  ≥ 2 courses OCS for asthma eosinophil count addressed and optimised
morbidities (e.g. breathing
also assess other features  ≥ 1 hospital admission/ED for asthma  Step up/down treatment as
pattern disorder, vocal  Diagnostic confirmation and
of poor control [box 1]  >3 SABA or PRN ICS/LABA prescribed above
cord dysfunction (ILO),
 Poor symptom control (as assessed  Consider other factors including phenotyping
deconditioning and obesity  Co-morbidity management
ACT<20 = uncontrolled RCP/ACT) smoking, mental health disease,
physical activity, weight and other pathologies i.e. through MDT (including
 RCP as above /ACT<20 bronchiectasis, sarcoid,
CONSENSUS PATHWAY FOR management, social influences SALT, psychologist)
 persisting daytime symptoms e.g., smoking-related COPD,
MANAGING UNCONTROLLED >2x/week, or nocturnal waking due to  Identify and manage co-  Adherence support and
morbidities including nasal hypersensitivity
ASTHMA IN ADULTS asthma in the previous 2 weeks, treatment optimisation
Adapted from: symptoms (rhinorrhoea, post pneumonitis etc.
 persisting airflow obstruction on (including initiation of
https://www.healthinnovationoxfor nasal drip, nasal blockage, loss  Referral to Leicester biologic medicines if
d.org/our-work/respiratory/asthma- spirometry (FEV1/FVC <70%, and/or Severe Asthma Service
of taste and smell), GORD appropriate)
biologics-toolkit/aac-consensus- FEV1 <80% predicted)
pathway-for-management-of-  Refer patients by 6 months (or
(ii) On maintenance OCS for asthma sooner) if remain uncontrolled
uncontrolled-asthma-in-adults/