📚 Module Overview
Asthma is a common long-term inflammatory disease of the airways. It is characterised by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Key symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath.
In the UK, 5.4 million people receive treatment for asthma. Pharmacists are integral to ensuring optimal management through patient education, inhaler technique counselling, and medication reviews.
🔍 Diagnosis & Assessment
Diagnosis involves a combination of clinical history and objective tests to demonstrate variable airflow obstruction and airway inflammation.
- Spirometry with Bronchodilator Reversibility (BDR): A significant increase in FEV₁ after inhaling a bronchodilator suggests asthma.
- FeNO (Fractional exhaled Nitric Oxide): Measures eosinophilic airway inflammation. A high reading supports a diagnosis of asthma.
- Peak Flow Variability: A diary showing significant diurnal variation in peak expiratory flow (PEF) over 2-4 weeks.
💊 Pharmacological Management
Recent guidelines mark a fundamental shift in asthma management for adults and children over 12. The aim is to move away from reliance on Short-Acting Beta-Agonist (SABA) relievers (like salbutamol) due to the risks associated with their overuse. The new standard is to provide an anti-inflammatory effect with every relieving dose.
The new pathway uses an ICS/formoterol combination inhaler as the cornerstone of treatment, for both symptom relief and maintenance. For monitoring details, refer to the SPS Drug Monitoring checker.
BTS/NICE/SIGN Stepwise Management (Adults & aYPs 12+) - 2024 Guidelines
| Step | Recommended Therapy | Key Clinical Points |
|---|---|---|
| Step 1 (First-Line) |
Anti-Inflammatory Reliever (AIR) Therapy Offer a low-dose ICS/formoterol* combination inhaler to be taken as needed (PRN) for symptom relief. |
This replaces SABA-only treatment. Every time a patient relieves their symptoms, they also get a dose of anti-inflammatory steroid. This is for patients with infrequent symptoms. |
| Step 2 (Step-up) |
Low-Dose MART** Therapy Offer a low-dose ICS/formoterol* combination inhaler for both daily maintenance AND as-needed relief. |
This is for patients who are highly symptomatic or have exacerbations. The same inhaler is used for prevention and relief, simplifying treatment and reducing SABA overuse. Patient education on max daily dose is critical. |
| Step 3 (Further Control) |
Moderate-Dose MART** Therapy Increase to a moderate-dose ICS/formoterol* combination inhaler, used for both daily maintenance AND as-needed relief. |
Used when low-dose MART is not enough to control symptoms. Continue to counsel on maximum daily dose. |
| Step 4 (Add-on) |
Add a LAMA*** Continue moderate-dose MART and add a Long-Acting Muscarinic Antagonist (LAMA), such as tiotropium. |
Provides additional bronchodilation through a different mechanism. Usually initiated by a specialist or those with expertise in asthma. |
| Step 5 (Specialist) |
Refer to Specialist Care Consider high-dose ICS, oral steroids, or biologic therapies (e.g., Omalizumab, Mepolizumab). |
For patients with severe, persistent asthma unresponsive to standard therapies. Requires specialist investigation and management. |
*Only certain ICS/formoterol inhalers (e.g. Symbicort, Fobumix, Fostair) are licensed for AIR/MART.
**MART = Maintenance And Reliever Therapy.
***LAMA = Long-Acting Muscarinic Antagonist.
For patients who are well-controlled on a traditional regimen (e.g., separate ICS preventer and SABA reliever), an immediate switch is not mandated. However, a discussion about the benefits and safety of switching to a SABA-free regimen (like MART) should take place at their next routine review.
⚡ Key Drug Interactions
Always check for interactions when a patient with asthma starts a new medication. Use a reliable source like the BNF or SPS.
| Asthma Drug | Interacting Drug Class | Effect & Management |
|---|---|---|
| All β₂-agonists (Salbutamol, Formoterol) |
Non-cardioselective β-blockers (e.g., Propranolol, Sotalol) |
Pharmacological antagonism. β-blockers can induce bronchospasm and reduce the effectiveness of β₂-agonists. This combination is generally contraindicated. Cardioselective β-blockers (e.g. Bisoprolol) should be used with caution under specialist advice. |
| All Patients | NSAIDs (e.g., Ibuprofen, Naproxen) |
Can induce bronchospasm in aspirin-sensitive asthma (up to 20% of adults). Patients should be warned, and paracetamol is a safer alternative for analgesia. |
| Theophylline | CYP1A2 Inhibitors (e.g., Ciprofloxacin, Clarithromycin) |
Inhibitors decrease theophylline metabolism, increasing levels and risk of toxicity (arrhythmias, seizures). Avoid if possible, or require significant dose reduction and monitoring. |
| Inhaled Steroids (ICS) (e.g., Fluticasone) |
Potent CYP3A4 Inhibitors (e.g., Ritonavir, Itraconazole) |
Can significantly increase systemic exposure to the ICS, leading to iatrogenic Cushing's syndrome and adrenal suppression. Avoid combination where possible. |
🚨 Management of an Acute Asthma Attack
Features include increasing breathlessness, wheeze, inability to complete sentences, PEF <50% of best, and poor response to reliever inhaler.
Immediate Management (Pre-Hospital)
Call 999. While waiting, the patient should sit upright and take one puff of their SABA inhaler via a spacer every 30-60 seconds, up to a maximum of 10 puffs.
Hospital Management
Based on the "SONY" acronym: Salbutamol, Oxygen, Nebulisers, hYdrocortisone/prednisolone.
| Intervention | Details |
|---|---|
| Oxygen | Controlled oxygen to maintain SpO₂ of 94-98%. |
| Systemic Steroids | Oral Prednisolone (e.g., 40-50mg) or IV Hydrocortisone. Reduces inflammation. Course of at least 5 days. |
| Nebulised Bronchodilators | Nebulised Salbutamol. Add Ipratropium Bromide for severe attacks. |
| IV Magnesium Sulphate | Considered for patients with acute severe asthma not responding to initial bronchodilator therapy. |
Bonus: Clinical Case Study
The Scenario: Identifying Poor Control
Patient: Mrs. Smith, 45, collects a prescription. You notice it's her 12th Salbutamol inhaler this year. Her record shows a prescription for a separate low-dose ICS inhaler.
S (Subjective): On questioning, Mrs. Smith admits to being woken by her asthma at night once a week. She feels she is "managing fine" with her blue inhaler and sometimes forgets her brown preventer one as it "doesn't seem to do much immediately".
O (Objective): Dispensing record shows 12 SABA inhalers and only 4 ICS inhalers in the last 12 months. This indicates SABA over-reliance and preventer under-use.
A (Assessment): Poor asthma control due to non-adherence with preventer therapy, likely due to a lack of understanding of its role. This puts her at high risk of a severe attack. She is a prime candidate for switching to the new MART pathway.
P (Plan):
- Educate: Explain that relying on the blue inhaler is risky. Introduce the concept of MART: "There is a new type of inhaler that works as both your preventer and reliever in one. It means you get a dose of the anti-inflammatory medicine every time you feel you need relief, which is much safer."
- Technique Check: Check and correct her current inhaler technique.
- Empower: "I am going to send a note to your GP recommending they consider switching you to one of these newer combination inhalers. It should simplify your treatment and give you better control."
- Action Plan: Provide a written asthma action plan. You can find templates and create one with your nurse via Asthma + Lung UK. Arrange an urgent follow-up review with the GP/Asthma Nurse.
❤️ Lifestyle & Patient Support
Holistic care is vital. Signposting patients to reliable resources empowers them to manage their condition effectively.
Asthma Support & Information
Specialist charity providing expert advice, support, and resources for people with asthma.
Asthma + Lung UK
Smoking Cessation
Smoking is a major trigger and worsens asthma. Quitting is essential.
NHS Smokefree
Managing Triggers
Identifying and avoiding personal triggers (e.g., dust, pollen, animals) is key.
Allergy UK provides information on managing allergies.
Mental Wellbeing
Living with a long-term condition can be stressful. Good mental health is key.
Mind provides support for mental health problems.
🎯 OSCE Preparation
Counselling on Inhaler Technique (pMDI + Spacer)
For videos and guides on using specific inhalers, an excellent resource is RightBreathe.
Scenario: A patient has been prescribed a Clenil Modulite pMDI and a Volumatic spacer for the first time.- Assemble: "First, take the caps off the inhaler and spacer. Shake the inhaler well and insert it into the back of the spacer."
- Breathe Out: "Breathe out gently, as far as is comfortable."
- Mouthpiece: "Put the mouthpiece of the spacer in your mouth and create a good seal with your lips."
- Actuate & Inhale: "Press the canister once to release a puff of medicine into the spacer. Then, breathe in slowly and steadily through your mouth until your lungs are full."
- Hold: "Hold your breath for about 10 seconds, or for as long as you comfortably can."
- Repeat: "If a second puff is needed, wait about 30 seconds before starting again from step 1."
- Clean & Check: "Rinse your mouth with water afterwards to prevent any soreness. Remind them to wash the spacer regularly according to the manufacturer's instructions."