ICS Inclusion: All adolescents with asthma should be on a treatment regimen that includes an inhaled corticosteroid (ICS). Prescribing short-acting β-agonist (SABA) alone is no longer recommended due to the increased risk of severe exacerbations and death.
Combination Therapy: For most adolescents, treatment can be started with an as-needed (reliever) combination of an ICS and a long-acting β-agonist (LABA).
Stable Regimens: Adolescents well controlled on traditional treatment with SABA and inhaled ICS should not be changed without consulting the adolescent’s care team or a senior clinician.
Treatment Adjustment: Treatment can be stepped up or down according to response. ICS should never be completely discontinued.
Inhaler Technique: Always check inhaler technique, compliance, and contributing factors before making any dose adjustments.
Background
Medications and Delivery Devices:
Inhaled Corticosteroid (ICS): Reduces inflammation in the airways.
Short-acting β-agonist (SABA): Provides quick relief by relaxing the muscles around the airways.
Metered Dose Inhaler (MDI): Delivers a specific amount of medication to the lungs in aerosol form.
Dry Powder Inhaler (DPI), including the Turbuhaler®: Delivers medication in powder form, requiring adequate inhalation technique.
Risks of SABA Alone: High use of SABA alone (>3 MDI canisters per year) and low use of ICS is associated with more severe asthma exacerbations and death.
Combination Therapy (ICS/LABA): Ensures use of anti-inflammatory with every reliever dose (anti-inflammatory reliever-based regimen). Currently, budesonide/formoterol is the only combination prescribed as a reliever.
Traditional Management: Daily ICS as a preventer and SABA as needed is effective and may be preferred for those already on a working regimen or with difficulties using DPI/Turbuhaler®.
Environmental Impact: MDI has a larger carbon footprint. Achieving good asthma control to reduce SABA need or switching to DPI can help reduce environmental impact.
Assessment
History:
Daytime Symptoms: Frequency and severity.
Need for Reliever: Number of doses per week.
Limitation of Activities: Impact on daily life.
Night or Morning Symptoms: Frequency and severity of symptoms at night or on waking.
Examination:
Inhaler Technique: Ensure correct usage of inhalers.
Comorbidities: Look for signs of allergic rhinitis and eczema.
Management
Investigations:
Most adolescents can be diagnosed clinically based on symptoms and response to treatment.
Investigations are necessary if other diagnoses are considered or if treatment needs to be stepped up beyond Step 3.
Spirometry should be performed in an accredited respiratory function laboratory, including bronchodilator response and possibly exercise or challenge tests.
Initiating Treatment:
Anti-inflammatory reliever-based regimen (budesonide/formoterol 200 mcg/6 mcg) can be started following an acute presentation or routine review.
If the adolescent is already on a traditional regimen, discuss changes with their long-term care provider.
Stepping Up or Down According to Response
Symptom Control Indicators:
Control Level
Daytime Symptoms
Need for Reliever
Limitation to Activity
Nighttime Symptoms
Good Control
≤2 days per week
≤2 days per week
None
None
Partial Control
>2 days per week
>2 days per week
Present
Present
Poor Control
>2 days per week
>2 days per week
Present
Present
Action Based on Control:
Good Control: Maintain current treatment. If good control is sustained for approximately 3 months, consider stepping down preventer treatment.
Partial Control: Review adherence and technique, then consider stepping up treatment.
Poor Control: Step up preventer medication and reassess. Ensure correct technique and adherence. Consider alternative diagnoses if control remains poor.
Severe Exacerbations: Review and step up treatment if a severe exacerbation occurs.
Additional Treatment Considerations
For Severe, Uncontrolled Asthma (Step 3 and Beyond):
Referral: Refer to a respiratory physician or specialist asthma service for further evaluation and management.
Fluticasone: Start at 125 mcg twice daily, can increase up to a total daily dose of 500 mcg.
Ciclesonide: Start at 80 mcg once daily, can increase up to 320 mcg as required.
Anti-inflammatory Reliever-based Asthma Action Plan
Written Action Plan: A core part of asthma management, detailing steps to take in case of worsening symptoms.
Indicators for Seeking Medical Attention:
DPI: Total of 12 actuations of budesonide/formoterol in a day.
MDI: Total of 24 inhalations of budesonide/formoterol in a day.
Management in Hospital
For Exacerbations:
Treat with SABA as per standard practice (see acute asthma guidelines).
Use SABA at home while waiting for ambulance if needed.
On discharge, resume budesonide/formoterol for symptom relief.
Approach to Asthma Not Responding to Treatment
Review the Following:
Correct asthma diagnosis.
Adherence to treatment.
Inhaler technique.
Contributing factors like
allergic rhinitis
obesity
obstructive sleep apnea
gastro-oesophageal reflux
dysfunctional breathing
depression/anxiety
smoking/vaping
environmental factors.
Socioeconomic factors affecting access to healthcare.
Poor adherence to treatment
Denying or disregarding asthma symptoms
Avoiding regular review appointments
Life events (new school, moving house, family disruption, absent parent)
Family problems (e.g. family conflict, family dysfunctions
Psychological distress (e.g. feelings of hopelessness, bereavement or recent loss)
Mental health problems (e.g. depression, emerging mood disorders
Risky use of alcohol/other substances
Communication problems
Consultation:
Consult respiratory/specialist asthma services if asthma control remains inadequate at Step 3 or if diagnosis is unclear.
Conditions that Confuse with Asthma
Conditions Characterised by Cough
Pertussis (whooping cough)
Gastro-oesophageal reflux
Rhinosinusitis/upper airway cough syndrome
Adverse effect of medicines (e.g. ACE inhibitors)
Bronchiectasis
Chronic obstructive pulmonary disease (COPD)
Pulmonary fibrosis
Large airway stenosis
Habit-cough syndrome
Inhaled foreign body
Conditions Characterised by Wheezing
Respiratory infections
Chronic obstructive pulmonary disease (COPD)
Upper airway dysfunction
Conditions Characterised by Difficulty Breathing
Breathlessness on exertion due to poor cardiopulmonary fitness
Hyperventilation
Anxiety
Chronic heart failure
Pulmonary hypertension
Lung cancer
Additional Resources
Green Prescribing: Strategies to reduce the environmental impact of asthma treatments.
Educational Materials: Information on inhaler techniques, asthma action plans, and environmental control measures.
Stepping Down in Adulthood for Asthma Management
Main Aim
Achieve good asthma control and minimize risks with the lowest effective dose of preventer medicines.
When to Consider Stepping Down
Consider stepping down when the patient has experienced good asthma control for 2-3 months and is at low risk of flare-ups.
General Tips
Confirm the patient’s actual treatment regimen before stepping down.
Address concerns about inhaled corticosteroids and propose a lower dose with an action plan for flare-ups.
Plan steps down before the patient finishes their current inhaler to resume the previous dose if control deteriorates.
Advise patients to step back up if asthma worsens, based on agreed criteria.
Monitor peak flow for 2 weeks before and 3-4 weeks after dose reduction to detect early deterioration.
Stepping Down Inhaled Corticosteroid Dose
Gradually reduce the dose for patients with well-controlled asthma on ICS/LABA combinations or ICS alone.
Reduce dose by stepping down through available formulations.
Note: Fluticasone furoate/vilanterol combinations contain moderate-to-high doses (100/25 mcg and 200/25 mcg).
Ceasing Inhaled Corticosteroid
Patients stopping regular low-dose ICS have an increased risk of flare-ups.
Stopping treatment may be necessary to confirm asthma diagnosis; close monitoring is needed.
Ceasing Long-acting Beta2 Agonist
Patients well controlled on ICS/LABA can continue the regimen long-term, reducing dose through available formulations.
Switching from ICS/LABA to ICS alone can lead to deterioration; advise patients to restart combination inhaler if asthma worsens after switching.
For fluticasone furoate/vilanterol, step down by switching to a lower dose ICS/LABA combination or ICS alone, with clear written instructions to avoid confusion.
Additional Considerations
Some patients may prefer to stay on high doses; monitor peak flow closely.
Ensure patients understand the changes and provide written instructions for new inhaler devices and dosing frequencies.
