Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ 
]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms (e.g., shortness of breath, wheezing); breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma. Consider stepping up treatment to step 1 therapy (i.e., adding an inhaled corticosteroid).[55]
[ ]
If exercise induces symptoms in patients whose asthma is otherwise well controlled with therapy, advise the patient to use an inhaled SABA immediately before exercise.[55]
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 1 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: leukotriene receptor antagonist (LTRA); long-acting beta agonist (LABA); sodium cromoglicate or nedocromil; theophylline.[55][90][91]
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 2 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: leukotriene receptor antagonist (LTRA); LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
MART LABA + low-dose ICS
Before stepping up to a new drug, always check the patient's inhaler technique and adherence to treatment, confirm the diagnosis of asthma, work with the patient to reduce or remove any triggers (e.g., smoking), and address comorbidities where feasible.[55]
If the patient's symptoms are not adequately controlled with low-dose ICS alone, BTS/SIGN recommend to add an inhaled LABA, either as a fixed-dose regimen (with SABA as needed; see above) or as combination maintenance and reliever therapy in a single inhaler (MART).[55]
Consider MART, particularly if the patient has a history of asthma attacks on a fixed-dose LABA and a low-dose ICS.[55] MART allows for the rapid onset of a reliever effect with formoterol; by also including a dose of ICS, MART ensures that the dose of preventer medication increases as the need for a reliever increases.[55] Therefore, a comprehensive self-management plan must be provided with a MART regimen.[55] MART may also lower the overall dose of ICS needed to prevent asthma attacks.[55]
The patient should not use intermittent reliever therapy (e.g., an inhaled SABA) alongside MART.[55]
One Cochrane review of serious adverse events when taking ICS with and without regular formoterol found no difference in risk of death in adults taking ICS-formoterol versus ICS alone.[109]
[ ]
There may be a number of inhaler formulations available, and formulations may vary between regions. Examples of suitable regimens are recommended here, based on BTS/SIGN guidelines. Consult a local drug formulary for more information.
Primary options
beclometasone/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
OR
budesonide/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 2 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: LTRA; LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 3 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: LTRA; LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
MART LABA + medium-dose ICS
Before stepping up to a new drug, always check the patient's inhaler technique and adherence to treatment, confirm the diagnosis of asthma, work with the patient to reduce or remove any triggers (e.g., smoking), and address comorbidities where feasible.[55]
If there was some improvement when a LABA was added as initial add-on therapy, but symptom control remains suboptimal, continue with the LABA and consider increasing the dose of ICS from low to medium (either as combined maintenance and reliever therapy [MART] or a fixed-dose regimen [see above]).[55] In practice, this is the most commonly used option at step 3.
MART allows for the rapid onset of a reliever effect with formoterol; by also including a dose of ICS, MART ensures that the dose of preventer medication increases as the need for a reliever increases.[55] Therefore, a comprehensive self-management plan must be provided with a MART regimen.[55] MART may also lower the overall dose of ICS needed to prevent asthma attacks.[55]
The patient should not use intermittent reliever therapy (e.g., an inhaled SABA) alongside MART.[55]
One Cochrane review of serious adverse events when taking ICS with and without regular formoterol found no difference in risk of death in adults taking ICS-formoterol versus ICS alone.[109]
[ ]
There may be a number of inhaler formulations available, and formulations may vary between regions. Examples of suitable regimens are recommended here, based on BTS/SIGN guidelines. Consult a local drug formulary for more information.
Primary options
beclometasone/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
OR
budesonide/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 3 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: LTRA; LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 3 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: LTRA; LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
MART LABA + low-dose ICS
Before stepping up to a new drug, always check the patient's inhaler technique and adherence to treatment, confirm the diagnosis of asthma, work with the patient to reduce or remove any triggers (e.g., smoking), and address comorbidities where feasible.[55]
If there was some improvement when combined maintenance and reliever therapy (MART) was started but symptom control remains suboptimal, continue with MART and consider adding an LTRA (see below).[55]
MART allows for the rapid onset of a reliever effect with formoterol; by also including a dose of ICS, MART ensures that the dose of preventer medication increases as the need for a reliever increases.[55] Therefore, a comprehensive self-management plan must be provided with a MART regimen.[55] MART may also lower the overall dose of ICS needed to prevent asthma attacks.[55]
The patient should not use intermittent reliever therapy (e.g., an inhaled SABA) alongside MART.[55]
One Cochrane review of serious adverse events when taking ICS with and without regular formoterol found no difference in risk of death in adults taking ICS-formoterol versus ICS alone.[109]
[ ]
There may be a number of inhaler formulations available, and formulations may vary between regions. Examples of suitable regimens are recommended here, based on BTS/SIGN guidelines. Consult a local drug formulary for more information.
Primary options
beclometasone/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
OR
budesonide/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose
education and environmental control
Treatment recommended for ALL patients in selected patient group
Ensure all patients at all steps of therapy have access to a self-management programme, which should include a written personalised asthma action plan and education.[55][56][85]
[ ]
This should be supported by regular professional review.[55][56] Advise the patient to take environmental control measures (e.g., reduce exposure to indoor and outdoor air pollution, tobacco smoke, and occupational and domestic allergens).[55][56] If you suspect an occupational cause, see Occupational asthma.
Consider breathing exercise programmes as part of an integrated approach to management, alongside pharmacological treatment, to improve the patient's quality of life and reduce symptoms.[55] Approaches used in practice include the Papworth method and the Buteyko method.[55] These techniques involve instruction by a trained therapist in exercises to reduce respiratory rate and minute volume, and to promote nasal, diaphragmatic breathing. Breathing exercises can lead to modest improvements in asthma symptoms and quality of life, and reduce bronchodilator requirement in adults with asthma, but have little effect on lung function or airway inflammation.[55][86][87][88][89] More studies are needed.[88]
[ ]
management of exercise-induced bronchoconstriction
Additional treatment recommended for SOME patients in selected patient group
Always review the patient's regular treatment and check their inhaler technique and adherence if they are experiencing exercise-induced symptoms; breakthrough exercise-induced bronchoconstriction may indicate poorly controlled asthma, potentially requiring stepping up of treatment.[55]
[ ]
If exercise induces symptoms (e.g., shortness of breath, wheezing) in patients whose asthma is otherwise well controlled with step 3 therapy, advise the patient to use an inhaled SABA immediately before exercise.[55] In addition, consider adding one of the following to their usual medication: LTRA; LABA; sodium cromoglicate or nedocromil; theophylline.[55][90][91]
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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