National asthma guidelines in the UK
Asthma is managed in the UK using a stepwise approach to control symptoms and reduce exacerbation risk, guided by NICE and BTS/SIGN recommendations.
Applies to adults, young people, and children in UK clinical practice.
Asthma management in the UK is guided by a stepwise approach to achieve and maintain symptom control while minimising the risk of exacerbations and medication side effects, with the initial step involving the use of a short-acting beta2-agonist (SABA) as reliever therapy for all patients; for adults and adolescents aged 12 and over, if asthma is uncontrolled on SABA alone or if they present with asthma-related symptoms two or more times a week, the first regular preventer therapy should be a low-dose inhaled corticosteroid (ICS), which is the cornerstone of asthma management due to its proven efficacy in reducing inflammation and the frequency of exacerbations; patients should be reviewed after 4-8 weeks on a new treatment, and if control remains inadequate on low-dose ICS, the next step typically involves adding a long-acting beta2-agonist (LABA) in a combination inhaler, as this has been shown to improve lung function and symptom control more effectively than increasing the ICS dose alone; for children aged 5-11, the step-up options differ, and after low-dose ICS, the next step is often to consider a leukotriene receptor antagonist (LTRA) before moving to a combined ICS/LABA inhaler; if control is not achieved on a low-dose ICS/LABA combination, management proceeds to step 4, which involves increasing the ICS dose to a medium dose within the combination inhaler, or considering the addition of a fourth drug such as an LTRA or, in some cases, a long-acting muscarinic antagonist (LAMA) or slow-release theophylline; step 5 involves referral to a severe asthma specialist for consideration of high-dose ICS, add-on therapies like tiotropium, or biological treatments for specific phenotypes, such as anti-IgE (omalizumab) for severe allergic asthma, anti-IL5 (mepolizumab, reslizumab) or anti-IL5 receptor (benralizumab) for severe eosinophilic asthma, or anti-IL4 receptor (dupilumab) for severe type 2 asthma; it is critical that at every stage, clinicians check and correct inhaler technique, reinforce adherence, and review and update a written asthma action plan with the patient, which should include clear instructions on daily management and how to recognise and respond to worsening symptoms or an asthma attack; for acute exacerbations, management depends on severity, but typically involves administration of high-dose SABA (via a spacer if using a pressurised metered-dose inhaler), a course of oral corticosteroids (e.g., prednisolone 40-50 mg daily for at least 5 days for adults), and supplemental oxygen if saturations are below 92%; patients presenting with life-threatening features (e.g., silent chest, cyanosis, poor respiratory effort, exhaustion, confusion) or a severe attack not responding to initial emergency treatment require immediate hospital admission; diagnosis should be confirmed with objective tests where possible, using spirometry to demonstrate reversible airflow obstruction (an increase in FEV1 of ≥12% and ≥200ml after SABA), or, if spirometry is normal, bronchial challenge testing or peak flow variability monitoring; in children under 5, diagnosis is more clinical, based on symptom pattern and response to a trial of treatment; smoking cessation support should be offered to all smokers with asthma, and annual influenza vaccination is recommended; comorbidities such as rhinitis, gastro-oesophageal reflux disease, and obesity should be identified and managed as they can worsen asthma control; regular structured reviews are essential, focusing on symptom control, exacerbation history, inhaler technique, and adherence, with stepping down treatment considered when asthma has been well-controlled for at least 3 months to find the lowest effective dose that maintains stability.
Diagnosis and management recommendations
Asthma diagnosis in the UK should be based on a combination of clinical history and objective tests, as symptoms alone are unreliable; a detailed history should identify characteristic symptom patterns such as episodic wheeze, shortness of breath, chest tightness, and cough, which are often worse at night or triggered by exercise, allergens, or cold air, and clinicians should actively seek evidence of variable expiratory airflow limitation, with spirometry being the initial test of choice to demonstrate obstruction (FEV1/FVC ratio below the lower limit of normal) and, crucially, bronchodilator reversibility testing, where an increase in FEV1 of more than 12% and 200ml from baseline after inhaling a short-acting beta2-agonist (SABA) like salbutamol provides strong supportive evidence, though in cases where spirometry is normal or inconclusive, further tests such as peak expiratory flow (PEF) variability monitoring over two to four weeks (a diurnal variation of more than 20% is significant) or direct bronchial challenge testing with histamine or methacholine may be necessary to confirm the diagnosis, while also considering and ruling out alternative diagnoses like vocal cord dysfunction, chronic obstructive pulmonary disease (COPD), or heart failure, particularly in smokers or older adults.
Management of asthma is a stepwise process focused on achieving good symptom control and minimising the risk of future exacerbations, starting with patient education about the condition, inhaler technique mastery, and the creation of a personalised asthma action plan; for adults and children aged five and over, the first step involves using a SABA as reliever medication for symptomatic relief, but if a patient requires their SABA three or more times a week, experiences night-time waking due to asthma, or has had an exacerbation requiring oral corticosteroids in the last two years, regular preventer therapy should be initiated, moving to Step 2, which entails a low-dose inhaled corticosteroid (ICS) such as beclomethasone or budesonide, which is the cornerstone of asthma management for most patients due to its anti-inflammatory effect; if control remains inadequate on a low-dose ICS alone after a review of adherence and inhaler technique, Step 3 involves adding a long-acting beta2-agonist (LABA) like salmeterol or formoterol in a combination inhaler with the ICS, and for patients who continue to have exacerbations or poor control, a further increase in the ICS dose or the addition of a leukotriene receptor antagonist (LTRA) such as montelukast can be considered; Step 4 involves increasing the ICS to a moderate or high dose, either within the combination inhaler or by introducing a separate ICS inhaler, and may also include a trial of an LTRA or, in severe cases, referral to a specialist for consideration of add-on therapies like long-acting muscarinic antagonists (LAMAs) or theophylline; Step 5 is for severe asthma and typically involves referral to a specialist severe asthma clinic for assessment for biological therapies such as anti-IgE (omalizumab), anti-IL5 (mepolizumab, reslizumab, benralizumab), or anti-IL4/13 (dupilumab) agents for eligible patients with specific phenotypes.
Regular review is paramount, focusing not only on symptom control using tools like the Royal College of Physicians three questions but also on assessing future risk factors, including the frequency of SABA use (over-reliance is a significant red flag), the history of exacerbations, and lung function, with the aim of maintaining the patient on the lowest effective dose of medication to minimise side effects; special consideration should be given to specific populations, such as pregnant women, where asthma should be actively managed as uncontrolled asthma poses a greater risk to the fetus than ICS medication, and smokers, who may exhibit a reduced response to ICS and require closer monitoring; for occupational asthma, a high index of suspicion is needed, and early referral for specialist assessment is crucial. The management of acute asthma exacerbations in a primary or secondary care setting follows a structured approach, starting with prompt assessment of severity using measures like PEF, oxygen saturation, and respiratory rate, with immediate treatment involving high-dose oxygen if hypoxaemic, high-dose nebulised SABA (often with ipratropium bromide in severe cases), and oral or intravenous corticosteroids, with severe cases requiring hospital admission for continuous nebuliser therapy, intravenous magnesium sulphate, and possibly non-invasive or invasive ventilation.
Prescribing and inhaler guidance
Asthma management in the UK centres on a stepwise approach to achieve symptom control and minimise the risk of exacerbations, with inhaled therapy being the cornerstone of treatment; for adults and adolescents aged 12 and over, treatment is initiated at Step 1 with a short-acting beta2 agonist (SABA) inhaler used as required for relief of symptoms, but for patients presenting with asthma symptoms more than twice a month, waking at night due to asthma, or who have had an exacerbation in the last two years, treatment should commence at Step 2 with regular low-dose inhaled corticosteroid (ICS) maintenance therapy, supplemented with a SABA for reliever therapy, as this provides a superior safety profile and better overall control compared to SABA-only treatment; the choice of inhaler device is critical and must be tailored to the individual patient, considering factors such as age, manual dexterity, coordination, inspiratory flow rate, and patient preference, with pressurised metered-dose inhalers (pMDIs) being commonly used but often requiring a spacer device for effective delivery, particularly in children and those with poor technique, while dry powder inhalers (DPIs) require a sufficient inspiratory effort to disperse the medication and are not suitable for young children or those with significantly impaired lung function.
It is imperative that clinicians check and correct inhaler technique at every opportunity, as incorrect use is a major cause of poor asthma control, and the patient's ability to use a device effectively should be a primary determinant in the prescribing decision rather than cost or habit; stepping up therapy should be considered if control remains inadequate despite good adherence and correct technique, moving to Step 3 which typically involves a combination of a low-dose ICS with a long-acting beta2 agonist (LABA) in a single inhaler for maintenance, with a separate SABA reliever, or alternatively, increasing the dose of ICS maintenance therapy, with the combination inhaler often preferred for adherence; if control is not achieved at Step 3, further options at Step 4 include increasing the ICS dose to a medium dose within the combination inhaler or considering add-on therapies such as a leukotriene receptor antagonist or a long-acting muscarinic antagonist; Step 5 involves referral to a specialist respiratory team for consideration of high-dose ICS, add-on treatments like theophylline, or monoclonal antibody therapies for severe eosinophilic asthma, alongside a thorough reassessment to exclude alternative diagnoses, confirm adherence, and address comorbidities; for children aged 5 to 12, the stepwise approach is similar but uses age-appropriate doses and devices, with pMDIs and spacers being the preferred option for most, and stepping up is done more cautiously; a written asthma action plan, tailored to the individual, is a fundamental component of management for all patients, detailing daily management, how to recognise and respond to worsening symptoms, and when to seek emergency help; regular structured reviews are essential to assess control, monitor growth in children, review inhaler technique, and adjust treatment accordingly, with the aim of using the lowest effective dose of ICS to maintain control and minimise the risk of long-term side effects.
Digital tools for asthma guidelines
Digital tools are increasingly integrated into asthma management, offering clinicians practical ways to support adherence to national guidelines, enhance patient self-management, and improve monitoring. The core function of these tools is to facilitate the delivery of key guideline recommendations, such as the creation and regular review of personalised asthma action plans (PAAPs). Digital platforms can streamline this process by providing templated, customisable plans that can be easily updated during consultations and shared electronically with patients, ensuring they always have access to the most current version.
For patients, smartphone apps and online portals can serve as interactive versions of their PAAP, providing clear instructions on daily management and steps to take during worsening symptoms or an attack, which can be particularly valuable for improving understanding and adherence, especially among younger patients or those with health literacy challenges. Beyond action plans, digital tools play a crucial role in monitoring, a cornerstone of effective asthma care; patients can use apps or connected devices, such as smart peak flow meters and inhaler sensors, to electronically record symptoms, peak expiratory flow (PEF) readings, and reliever inhaler use. This data can be transmitted directly to a clinical system or reviewed by the clinician during consultations, providing an objective, longitudinal view of asthma control that is more reliable than retrospective patient recall, thereby enabling earlier identification of deteriorating control and more proactive adjustments to treatment.
For clinicians, digital decision-support systems integrated into electronic health records (EHRs) can prompt guideline-based actions, such as checking inhaler technique at annual reviews, assessing adherence, or considering step-down therapy when control is good, thus helping to standardise care and reduce clinical variation. Remote monitoring platforms also support the shift towards more personalised care, allowing for virtual reviews for stable patients and prioritising face-to-face appointments for those with unstable asthma, which can improve healthcare efficiency. However, the implementation of these tools requires careful consideration of several practical factors within the UK context, including ensuring digital accessibility for all patient groups to avoid widening health inequalities, verifying that any apps recommended to patients comply with data protection regulations like the UK GDPR and meet NHS digital technology standards, and critically appraising the clinical evidence behind commercial devices to ensure they provide accurate and meaningful data. Ultimately, when selected and used appropriately, digital tools should be viewed as an adjunct to, not a replacement for, clinical judgement and the essential clinician-patient relationship, serving to enhance the delivery of guideline-driven, patient-centred asthma care.