Stepwise treatment of chronic asthma
Stepwise treatment of chronic asthma means reviewing medication regularly and stepping it up or down, aiming to use the least treatment needed to manage symptoms.
Remember
Check that the treatment is being taken and the inhaler used properly before stepping up, then add an inhaled corticosteroid (a steroid breathed in) to treat the inflammation; a long-acting beta-2 agonist (a drug that keeps the airway muscle relaxed for hours) is added to it, never used alone.
In asthma the airway muscle tightens (bronchoconstriction) and the airway lining becomes inflamed. A reliever such as salbutamol, a short-acting beta-2 agonist (SABA), relaxes the muscle within minutes but does nothing for the inflammation underneath.
Treatment is reviewed regularly and may be stepped up or down as symptoms require. Signs that treatment should step up include reliever use on three or more days a week, night waking on one or more nights a week, or an attack needing oral steroids.
Before any step up, check adherence (taking medicine as prescribed) and inhaler technique.
- Step 1 is a reliever inhaler, but current guidance favours treatment based on an inhaled corticosteroid from the outset rather than a SABA alone, to lower the risk of attacks. For people aged 12 and over it offers a low-dose inhaled steroid with formoterol (a long-acting beta-2 agonist that works quickly) in one inhaler, taken as needed.
- Step 2: a regular inhaled corticosteroid (ICS) such as beclomethasone, a steroid breathed in that reduces inflammation in the airways.
- Step 3: a long-acting beta-2 agonist (LABA) such as salmeterol or formoterol, if symptoms persist despite an ICS. It does not reduce inflammation by itself, so it must always be given with an ICS, usually in the same inhaler. Current UK guidance suggests considering low-dose maintenance and reliever therapy (MART), a single ICS/formoterol inhaler used daily and as the reliever, for people who remain uncontrolled on regular low-dose ICS plus a reliever.
- Step 4: other add-ons are considered, such as a higher-dose ICS or a leukotriene receptor antagonist (a tablet that blocks leukotrienes, chemical signals that narrow the airways and fuel inflammation).
- Step 5: referral to specialist care, which can involve oral steroids (steroid tablets) or biological therapies (injected antibodies that block specific allergic or inflammatory signals).
Key facts
- Signs to step up
- they include reliever use on three or more days a week, night waking on one or more nights a week, or an attack needing oral steroids.
- Reliever versus preventer
- a reliever such as salbutamol relaxes the airway muscle, while a preventer (an inhaled corticosteroid) calms the inflammation.
- LABA rule
- a long-acting beta-2 agonist is never used alone in asthma, because it has no anti-inflammatory effect.
- Before stepping up
- check adherence (taking medicine as prescribed) and inhaler technique.
- Current guidance
- people aged 12 and over on a reliever alone are moved to a low-dose inhaled corticosteroid with formoterol inhaler, taken as needed.
- Steroid tablets
- they are kept for short courses in attacks, or for specialist-led treatment of severe asthma.
Exam traps
- Taking a short-acting beta-2 agonist on a regular daily schedule does not improve poorly controlled asthma, because it treats tight airway muscle but leaves the inflammation untouched. For someone relying on a reliever alone, frequent reliever use is a reason to add an inhaled corticosteroid.
- Swapping an inhaled corticosteroid for a long-acting beta-2 agonist alone is unsafe, because the long-acting beta-2 agonist has no anti-inflammatory effect, so protection against airway inflammation and attacks is lost.
- A higher dose of inhaled corticosteroid is reasonable only once the current dose is genuinely being taken with good technique. Before that, the extra drug might never reach the lungs and adds side effects for no gain.
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