sign101

British Guideline on the MAnAGeMent of AsthMA
44
Figure 3: Summary of step 3 in adults and children>5 years: Add-on therapy
Good response to lABA and good
control:
� Continue lABA
4.3.4 COMBINATION INHALERS
inAdeQuAte Control
on low dose inhaled steroids
Add inhaled long-acting β 2 agonist (lABA)
Assess control of asthma
Benefit from LABA but control still
inadequate:
� Continue lABA and
� increase inhaled steroid dose to
800 mcg/ day (adults) and 400
mcg/day (children 5-12 years)
if control still
inadequate go to
step 4
no response to lABA:
� stop lABA
� increase inhaled steroid dose to
800 mcg/ day (adults) and 400
mcg/day (children 5-12 years)
Control still inadequate:
� trial of other add-on therapy eg
leukotriene receptor antagonist or
theophylline
if control still
inadequate go to
step 4
In efficacy studies, where there is generally good compliance, there is no difference in efficacy
in giving inhaled steroid and a long-acting β 2 agonist in combination or in separate inhalers. 318
In clinical practice, however it is generally considered that combination inhalers aid compliance
and also have the advantage of guaranteeing that the long-acting β 2 agonist is not taken without
the inhaled steroids.
; Combination inhalers are recommended to:
guarantee that the long-acting β agonist is not taken without inhaled steroid
2
improve inhaler adherence.
use of a single combination inhaler (sMArt)
In selected adult patients at step 3 who are poorly controlled or in selected adult patients at step
2 (above BDP 400 micrograms/day and poorly controlled), the use of budesonide/formoterol
in a single inhaler as rescue medication instead of a short-acting β 2 agonist, in addition to its
regular use as controller therapy has been shown to be an effective treatment regime. 323-327 When
this management option is introduced the total regular dose of daily inhaled corticosteroids
should not be decreased. The regular maintenance dose of inhaled steroids may be budesonide
200 micrograms twice daily or budesonide 400 micrograms twice daily. Patients taking rescue
budesonide/formoterol once a day or more on a regular basis should have their treatment
reviewed. Careful education of patients about the specific issues around this management
strategy is required.
>12
years
5-12
years
1 ++ 1 ++