17th February 2025

Management of chronic asthma

Both the BTS (British Thoracic Society) 2019 guidelines and NICE 2017 guidelines cover the management of acute asthma. The following is a summary of the NICE stepwise management of asthma:

Step 1 (new diagnosis): short-acting beta-2 agonist (SABA)
Step 2 (not controlled with SABA or new diagnosis of asthma with moderate/severe symptoms, e.g. nighttime waking or frequent exacerbations): SABA + low-dose inhaled corticosteroid (ICS)
Step 3: SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
Step 4: SABA + low-dose ICS + long-acting beta agonist (LABA); continue LRTA if good response, otherwise stop
Step 5: SABA ± LTRA; switch ICS + LABA for maintenance and reliever therapy (MART) including a low-dose ICS
Step 6: SABA ± LTRA + medium-dose ICS MART
Step 7: SABA ± LTRA + one of: high-dose ICS (fixed-dose regimen, not as a MART) or trial of long-acting muscarinic receptor antagonist (LAMA) or theophylline; referral to specialist asthma service

Guidelines by BTS are very similar, although they advise prescribing a leukotriene receptor antagonist in step 4 rather


SABA: salbutamol, terbutaline ICS: beclometasone, budesonide, fluticasone, mometasone LTRA: montelukast, zafirlukast LABA: salmeterol, formoterol MART (maintenance and reliever therapy – typically an ICS and fast-acting LABA in one inhaler): beclometasone/formoterol, budesonide/formoterol

SABA: salbutamol, terbutaline

ICS: beclometasone, budesonide, fluticasone, mometasone

LTRA: montelukast, zafirlukast

LABA: salmeterol, formoterol

MART (maintenance and reliever therapy – typically an ICS and fast-acting LABA in one inhaler): beclometasone/formoterol, budesonide/formoterol

Box 1 Common medications used in asthma


Low dose: less than 400 mcg of budesonide or equivalent Intermediate dose: 400-800 mcg of budesonide or equivalent High dose: more than 800 mcg of budesonide or equivalent

Low dose: less than 400 mcg of budesonide or equivalent

Intermediate dose: 400-800 mcg of budesonide or equivalent

High dose: more than 800 mcg of budesonide or equivalent

Box 2 ICS dosing