The NICE view
For children under 5 years with suspected or confirmed asthma, NICE recommends a SABA initially and then alongside maintenance therapy. An ICS should be introduced at a paediatric moderate dose for 8 weeks if a SABA is not providing adequate control. The ICS should then be stopped and the child assessed.7
If there is no improvement an alternative diagnosis should be considered. If symptoms resolve but then return within 4 weeks, paediatric low dose ICS should be reintroduced. If symptoms improve but then return more than 4 weeks later, repeat the 8-week trial with paediatric moderate dose ICS.
If suspected asthma is uncontrolled with a paediatric low dose of ICS (with a SABA) consider adding an LTRA. If the LTRA remains uncontrolled, then stop the LABA and refer to specialist care.
For children over 5 and adults, NICE sets out the treatment steps where symptoms are no longer adequately controlled (see Table 1). Decreasing maintenance therapy is not recommended until the patient’s asthma has been controlled with their current maintenance therapy for at least three months. Stepping down medication should be done in an order that considers the clinical effectiveness of each drug when introduced, side effects and patient preference.7
Table 1: NICE asthma pharmacological treatment pathway for adults and children aged 5 or over7
| Asthma stage | Adult | Child or adolescent (5-16 years) |
| Newly diagnosed initial therapy or adequate control with SABA: | SABA | SABA |
| If a SABA reliever is needed ≥3 times a week or cannot control asthma alone: |
Low dose ICS +SABA |
Paediatric low dose ICS +SABA |
| First add-on: |
Low dose ICS +LTRA +SABA |
Paediatric low dose ICS +LTRA +SABA |
| If response with add-on is inadequate try: |
Low dose ICS+LABA (individually) +/-LTRA +SABA |
Paediatric low dose ICS (+/-LTRA) +LABA +SABA |
| Try a combination maintenance and reliever therapy (MART): |
Low dose ICS+LABA as (MART) +/-LTRA +SABA |
Paediatric low dose ICS+LABA (MART or fixed dose ICS+LABA)(+/-LTRA) +SABA |
| Stepping up: |
moderate dose ICS + LABA (MART/fixed dose ICS+LABA) +/-LTRA +SABA |
Paediatric moderate dose ICS+LABA (MART/fixed dose ICS+LABA)) (+/-LTRA) +SABA |
| Stepping up: |
Trial of: High dose ICS+LABA +/-LTRA +SABA or +LAMA or +theophylline or referral to specialist |
Referral to specialist care - in interim consider paediatric high dose ICS+LABA (MART/fixed dose) +SABA or trial of an additional drug, eg theophylline |
Derived from NICE NG80 ‘Asthma: diagnosis, monitoring and chronic asthma management’