Principles of pharmacological management in children and adults

Pharmacological management

The aim of asthma management is control of the disease. Complete control is defined as:

• no daytime symptoms
• no night-time awakening due to asthma
• no need for rescue medication
• no asthma attacks
• no limitations on activity including exercise
• normal lung function (in practical terms FEV1and/or PEF >80% predicted or best)
• minimal side effects from medication.

Approach to management

• 1. Start treatment at the level most appropriate to initial severity.
• 2. Achieve early control.
• 3. Maintain control by:
  • increasing treatment as necessary
  • decreasing treatment when control is good

Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and eliminate trigger factors.

Intermittent reliever therapy:

• Prescribe an inhaled short-acting beta2 agonist as short-term reliever therapy for all patients with symptomatic asthma.
• anyone prescribed more than one short-acting bronchodilator inhaler device a month should be identified and have their asthma assessed urgently and measures taken to improve asthma control if this is poor.

Regular preventer therapy:

• Inhaled corticosteroids are the recommended preventer drug for adults and children for achieving overall treatment goals
  
• Give inhaled corticosteroids initially twice daily (except ciclesonide which is given once daily)
  
• Once-a-day inhaled corticosteroids at the same total daily dose can be considered if good control is established
  
• Clinicians should be aware that higher doses of inhaled corticosteroids may be needed in patients who are smokers or ex-smokers.

Initial add-on therapy:

The first choice of add-on therapy to inhaled corticosteroids in adults is an inhaled long-acting beta 2 agonist, which should be considered before increasing the dose of inhaled corticosteroids.

In children aged five and over, an inhaled long-acting beta 2 agonist or a leukotriene receptor antagonist can be considered as initial add-on therapy

Combination inhalers:

• In efficacy studies, where there is generally good adherence, there is no difference in efficacy in giving inhaled corticosteriod and a long-acting beta2 agonist in combination or in separate inhalers. In clinical practice, however, it is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting beta2 agonist is not taken without the inhaled corticosteroid
  • Combination inhalers are recommended to:
    • guarantee that the long-acting beta2 agonist is not taken without inhaled corticosteroid
    • improve inhaler adherence

Additional Controller therapies:

• If control remains poor on low-dose (adults) or very low-dose (children aged five and over) inhaled corticosteroids plus a long-acting beta 2 agonist, recheck the diagnosis, assess adherence to existing medication and check inhaler technique before increasing therapy.
  • If asthma control remains suboptimal after the addition of an inhaled long-acting beta2 agonist then:
    • increase the dose of inhaled corticosteroids from low dose to medium dose in adults or from very low dose to low dose in children (5-12 years), if not already on these doses. or
    • consider adding a leukotriene receptor antagonist

Reference:

• (1) British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) 2019. British Guideline on the Management of Asthma. A national clinical guideline.
• (3) National Institute for Health and Clinical Excellence (NICE) 2021 Asthma: diagnosis, monitoring and chronic asthma management