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The Pharmaceutical Journal
Vol 270 No 7234 p141
1 February 2003

Related websites
BTS: British Thoracic Society (www.brit-thoracic.org.uk)
SIGN: Scottish Intercollegiate Guidelines Network (www.sign.ac.uk)

Asthma guideline encourages use of other drugs before raising steroid dose

An updated guideline on managing asthma was published earlier this week by the British Thoracic Society and the Scottish Intercollegiate Guidelines Network.

The joint guideline replaces asthma guidelines previously published separately by the BTS and SIGN. Changes include new sequences of treatment, with an emphasis on the use of add-on therapies in the early stage of the disease before resorting to higher doses of inhaled corticosteroids. The guideline also encourages the use of educational materials and individual asthma action plans to help patients monitor and manage their own symptoms.

The drug management section of the guideline gives a step-wise approach to treatment (see Panel below) with the aim of gaining and maintaining control of asthma symptoms and then stepping down when control is good. It suggests that patients should be regularly reviewed as treatment is stepped down and that patients should be maintained on the lowest possible dose of an inhaled steroid. Reductions in inhaled steroid doses should be slow because patients deteriorate at different rates, it says. It suggests that reductions are considered every three months, decreasing the dose by approximately 25–50 per cent each time.

Stepwise management of asthma in adults

• Step 1: Mild intermittent asthma Inhaled short-acting b₂-agonist as required

• Step 2: Regular preventer therapy Add inhaled steroid 200–800µg/day*

• Step 3: Add-on therapy Add inhaled long-acting b₂-agonist (LABA), then assess control of asthma:

• Good response to LABA — continue therapy

• Benefit from LABA but control inadequate — continue LABA and increase steroid dose to 800µg/day*

• No response to LABA — stop LABA and increase steroid dose to 800µg/day*. If control is still inadequate, try other therapies, such as leukotriene receptor antagonist or sustained-release theophylline

• Step 4: Persistent poor control Consider trials of increasing inhaled steroid up to 2,000µg/day* or add fourth drug (eg, leukotriene receptor antagonist, SR theophylline, oral b₂-agonist)

• Step 5: Continuous or frequent use of oral steroids Use daily oral steroid at lowest dose providing adequate control, maintain high dose inhaled steroid, consider other treatments to minimise use of oral steroid, refer patient for specialist care

(* beclometasone equivalent dose)

The guideline also includes advice on the use of intravenous magnesium and the potential use of continuous nebulisation of a b₂-agonist for severe or life-threatening attacks. Non-pharmacological management and complementary and alternative medicines are also included.

If patients experience exercise-induced asthma, treatment should be reviewed. In patients taking inhaled steroids who are otherwise well controlled, the following treatments should be considered: leukotriene receptor agonists, long-acting b₂-agonists, cromoglicate and related therapies, oral b₂-agonists, and theophyllines.

The new guideline is published as a supplement to the February issue of Thorax (2003;58), and can be downloaded from the BTS website.