1. 1 British Guideline on the Management of Asthma BTS/SIGN British Guideline on the Management of Asthma, May 2008 Introduction Diagnosis Non-pharmacological management Pharmacological management Inhaler devices Management of acute asthma Special situations Organisation and delivery of care, and audit Patient education and self- management Development of the guideline

2. 2 Asthma control BTS/SIGN British Guideline on the Management of Asthma, May 2008 Aim is for asthma control:  no daytime symptoms  no night time awakening due to asthma  no need for rescue medication  no exacerbations  no limitations on activity including exercise  normal lung function Before moving up to the next step:  Check compliance  Check inhaler technique  Eliminate trigger factors At any stage, step down therapy once asthma is controlled

3. 3 Measuring clinical outcomes BTS/SIGN British Guideline on the Management of Asthma, May 2008 Ask the patient three key questions: In the last week (or month): 1.have you had difficulty sleeping because of your asthma symptoms (including cough)? 2.have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? 3.has your asthma interfered with your usual activities (e.g. housework, work/school etc.)?

4. 4 Step 1: Mild intermittent asthma Step 5: Continuous or frequent use of oral steroids Step 4: Persistent poor control Step 3: Add-on therapy Step 2: Regular preventer therapy Stepwise management of asthma in adults BTS/SIGN British Guideline on the Management of Asthma, May 2008

5. 5 Step 1: Mild intermittent asthma Inhaled short acting ß 2 agonist as required Stepwise management of asthma in adults BTS/SIGN British Guideline on the Management of Asthma, May 2008

6. 6 Step 2: Regular preventer therapy BTS/SIGN British Guideline on the Management of Asthma, May 2008 Inhaled steroids should be prescribed for patients: With exacerbation of asthma in the last 2 years Using inhaled beta 2 agonists three times a week or more Symptomatic three times a week or more Waking one night a week or more Start patients at inhaled steroid dose appropriate to disease severity (e.g. adults: 400 micrograms per day; children 5-12 years: 200 micrograms per day; children under 5 years: higher doses may be required to ensure consistent drug delivery) Use lowest dose at which effective control of asthma is maintained Monitor children’s height on a regular basis In children on inhaled steroids with decreased consciousness, check blood glucose levels urgently and consider IM hydrocortisone In adults doubling the dose of inhaled steroids at the time of exacerbation is of unproven value Inhaled steroids are the most effective preventer drug for adults and children for achieving overall treatment goals

7. 7 Stepwise management of asthma in adults BTS/SIGN British Guideline on the Management of Asthma, May 2008 Step 3: Add-on therapies 1. Add inhaled long-acting ß 2 agonist (LABA) 2. Assess control of asthma: good response to LABA – continue LABA benefit from LABA but control still inadequate – continue LABA and increase inhaled steroid dose to 800 micrograms/day * (if not already on this dose) no response to LABA – stop LABA and increase inhaled steroid to 800 micrograms/day *. If control still inadequate, institute trial of other therapies (e.g. leukotriene receptor antagonist or SR theophylline) Step 1: Mild intermittent asthma Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent

8. 8 Current advice from the CHM www.mhra.gov.uk December 2006, updated February 2007 In the management of chronic asthma, formoterol and salmeterol should: –be added only if regular use of standard-dose ICS has failed to control asthma adequately –not be initiated in patients with rapidly deteriorating asthma –be introduced at a low dose and the effect properly monitored before considering dose increase –be discontinued in the absence of benefit –be reviewed as appropriate: stepping down therapy should be considered when good long-term asthma control has been achieved Patients should report any deterioration in symptoms following initiation of treatment with a LABA

9. 9 So where does Symbicort SMART ® fit in the management of asthma? BTS/SIGN British Guideline on the Management of Asthma, May 2008 In adult patients at step 3, who are poorly controlled: –The use of budesonide/formoterol in a single inhaler (Symbicort SMART ® ) as rescue medication instead of a short-acting β 2 agonist, in addition to its regular use as a controller treatment, has been shown to be an effective treatment option –Before instituting this management, careful patient education is required

10. 10 Step 4: Persistent poor control Consider trials of: increasing inhaled steroid up to 2000mcg/day * addition of fourth drug (e.g. leukotriene receptor antagonist, SR theophylline, ß 2 agonist tablet) Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Stepwise management of asthma in adults BTS/SIGN British Guideline on the Management of Asthma, May 2008

11. 11 Step 5: Continuous or frequent use of oral steroids Use daily steroid tablet in lowest dose providing adequate control Maintain high dose inhaled steroid at 2000mcg/day * Consider other treatments to minimise the use of steroid tablets Refer patient for specialist care Step 1: Mild intermittent asthma Step 3: Add-on therapy Step 2: Regular preventer therapy Start at dose of inhaled steroid appropriate to severity of disease. * BDP or equivalent Step 4: Persistent poor control Stepwise management of asthma in adults BTS/SIGN British Guideline on the Management of Asthma, May 2008

12. 12 Asthma – treatment summary BTS/SIGN guidance is the basis for treatment Use the RCP three questions to help assess control, not (just) PEFR and FEV 1 Start at step appropriate for patient’s asthma, and step down when control achieved and patient is stable Safety issues and concerns regarding high-dose inhaled steroids and long-acting beta 2 -agonists