Asthma-Managing-Asthma NICE 2017

Managing asthma
NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/asthma
NICE Pathway last updated: December 2017
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
Asthma Page 1 of 25
© NICE 2018. All rights reserved. Subject to Notice of rights.
Managing asthma NICE Pathways
Asthma Page 2 of 25
1 Person with suspected or confirmed asthma
No additional information
2 Principles of care
Take into account the possible reasons for uncontrolled asthma [See page 20], before starting
or adjusting medicines for asthma in adults, young people and children. These may include:
alternative diagnoses
lack of adherence
inappropriate inhaler technique
smoking (active or passive)
occupational exposures
psychosocial factors
seasonal or environmental factors.
After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8
weeks (see monitor and review).
If ICS maintenance therapy is needed, offer regular daily ICS rather than intermittent or 'when
required' ICS therapy.
Adjust the dose of ICS maintenance therapy over time, aiming for the lowest dose required for
effective asthma control.
Ensure that a person with asthma can use their inhaler device:
at any asthma review, either routine or unscheduled

whenever a new type of device is supplied.
For guidance on managing non-adherence to medicines in people with asthma, see NICE's
recommendations on supporting adherence.
Consider using risk stratification [See page 20] to identify people with asthma who are at
increased risk of poor outcomes, and use this information to optimise their care. Base risk
stratification on factors such as non-adherence to asthma medicines, psychosocial problems
and repeated episodes of unscheduled care for asthma.
Asthma Page 3 of 25
Doses of inhaled corticosteroids
ICS doses and their pharmacological strengths vary across different formulations. In general,
people with asthma should use the smallest doses of ICS that provide optimal control for their
asthma, in order to reduce the risk of side effects.
The following definitions can be used to guide doses of ICSs.
For adults aged 17 and over:
less than or equal to 400 micrograms budesonide or equivalent would be considered a low
dose
more than 400 micrograms to 800 micrograms budesonide or equivalent would be
considered a moderate dose
more than 800 micrograms budesonide or equivalent would be considered a high dose.
For children and young people aged 16 and under:
less than or equal to 200 micrograms budesonide or equivalent would be considered a

paediatric low dose
more than 200 micrograms to 400 micrograms budesonide or equivalent would be
considered a paediatric moderate dose
more than 400 micrograms budesonide or equivalent would be considered a paediatric high
dose.
3 Drug treatment
No additional information
4 Under 5s
These recommendations are for children under 5 with newly suspected or confirmed asthma, or
with asthma symptoms that are uncontrolled on their current treatment. Where the
recommendations represent a change from traditional clinical practice, children whose asthma
is well controlled on their current treatment should not have their treatment changed purely to
follow this guidance.
Offer a SABA as reliever therapy to children under 5 with suspected asthma. This should be
used for symptom relief alongside all maintenance therapy.
Asthma Page 4 of 25
Consider an 8 week trial of a paediatric moderate dose of an ICS in children under 5 with:
symptoms at presentation that clearly indicate the need for maintenance therapy (for
example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
suspected asthma that is uncontrolled with a SABA alone.
After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms:
if symptoms did not resolve during the trial period, review whether an alternative diagnosis
is likely
if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the
ICS at a paediatric low dose as first-line maintenance therapy
if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat
the 8 week trial of a paediatric moderate dose of ICS.
If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as

maintenance therapy, consider an LTRA1 in addition to the ICS.
If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS and an
LTRA as maintenance therapy, stop the LTRA and refer the child to a healthcare professional
with expertise in asthma for further investigation and management.
See principles of care [See page 3] for information on ICS doses.
Inhaled corticosteroids
The following recommendation is an extract from NICE technology appraisal guidance on

inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12
years.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS is
considered appropriate, the least costly product that is suitable for an individual child (taking into
consideration technology appraisal guidance 38 and 10), within its marketing authorisation, is
recommended.
This recommendation should be read in conjunction with the recommendations in inhaler

devices [See page 12].
NICE has written information for the public on inhaled corticosteroids for the treatment of
chronic asthma in children under the age of 12 years.
Asthma Page 5 of 25
1
At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children
and young people aged under 18 for this indication.
Asthma Page 6 of 25
5 Person aged 5 to 16
These recommendations are for children and young people with newly diagnosed asthma or
asthma that is uncontrolled on their current treatment. Where the recommendations represent a
change from traditional clinical practice, children and young people whose asthma is well
controlled on their current treatment should not have their treatment changed purely to follow
guidance.
Offer a SABA as reliever therapy to children and young people (aged 5 to 16) with newly
diagnosed asthma.
For children and young people (aged 5 to 16) with asthma who have infrequent, short-lived
wheeze and normal lung function, consider treatment with SABA reliever therapy alone.
Offer a paediatric low dose of an ICS as the first-line maintenance therapy to children and
young people (aged 5 to 16) with:
asthma that is uncontrolled with a SABA alone.
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric low dose
of ICS as maintenance therapy, consider an LTRA1 in addition to the ICS and review the
response to treatment in 4 to 8 weeks.
of ICS and an LTRA as maintenance therapy, consider stopping the LTRA and starting a LABA2
in combination with the ICS.
of ICS and a LABA as maintenance therapy, consider changing their ICS and LABA
maintenance therapy to a MART regimen3 with a paediatric low maintenance ICS dose. Ensure
that the child or young person is able to understand and comply with the MART regimen.
If asthma is uncontrolled in children and young people (aged 5 to 16) on a MART regimen with a
paediatric low maintenance ICS dose, consider increasing the ICS to a paediatric moderate
maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS
and a LABA, with a SABA as a reliever therapy).
Asthma Page 7 of 25
1
At the time of publication (November 2017), not all LTRAs have a UK marketing authorisation for use in children
2
At the time of publication (November 2017), not all LABAs have a UK marketing authorisation for use in children
3
At the time of publication (November 2017), MART regimens did not have a UK marketing authorisation for use in
children and young people (aged under 12) for this indication. The prescriber should follow relevant professional
guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the
GMC's Prescribing guidance: prescribing unlicensed medicines for further information.
Asthma Page 8 of 25
If asthma is uncontrolled in children and young people (aged 5 to 16) on a paediatric moderate
maintenance ICS dose with LABA (either as MART or a fixed-dose regimen), consider seeking
advice from a healthcare professional with expertise in asthma and consider either:
increasing the ICS dose to paediatric high maintenance dose (only as part of a fixed-dose
regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, theophylline).
Inhaled corticosteroids and long-acting beta-2 agonists
Under 12s
The following recommendations are from NICE technology appraisal guidance on inhaled
corticosteroids for the treatment of chronic asthma in children under the age of 12 years.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS is
considered appropriate, the least costly product that is suitable for an individual child (taking into
consideration technology appraisal guidance 38 and 10), within its marketing authorisation, is
recommended.
For children under the age of 12 years with chronic asthma in whom treatment with an ICS and
LABA is considered appropriate, the following apply.
The use of a combination device within its marketing authorisation is recommended as an

option.
The decision to use a combination device or the two agents in separate devices should be
made on an individual basis, taking into consideration therapeutic need and the likelihood of
treatment adherence.
If a combination device is chosen then the least costly device that is suitable for the
individual child is recommended.
These recommendation should be read in conjunction with the recommendations in inhaler

chronic asthma in children under the age of 12 years.
Asthma Page 9 of 25
Person aged 12 or over
corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and
over.
For adults and children aged 12 years and older with chronic asthma in whom treatment with an
ICS is considered appropriate, the least costly product that is suitable for an individual, within its
marketing authorisation, is recommended.
ICS and LABA is considered appropriate, the following apply.

option.
individual is recommended.

chronic asthma in adults and in children aged 12 years and over.
6 Person aged 17 or over
These recommendations are for people with newly diagnosed asthma or asthma that is
uncontrolled on their current treatment. Where the recommendations represent a change from
traditional clinical practice, people whose asthma is well controlled on their current treatment
should not have their treatment changed purely to follow this guidance.
Offer a SABA as reliever therapy to adults (aged 17 and over) with newly diagnosed asthma.
For adults (aged 17 and over) with asthma who have infrequent, short-lived wheeze and normal
lung function, consider treatment with SABA reliever therapy alone.
Asthma Page 10 of 25
Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over)
with
asthma that is uncontrolled with a SABA alone.
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance
therapy, offer a LTRA in addition to the ICS and review the response to treatment in 4 to 8
weeks.
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as
maintenance therapy, offer a LABA in combination with the ICS, and review LTRA treatment as
follows:
discuss with the person whether or not to continue LTRA treatment

take into account the degree of response to LTRA treatment.
If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or
without an LTRA, as maintenance therapy, offer to change the person's ICS and LABA
maintenance therapy to a MART regimen with a low maintenance ICS dose.
If asthma is uncontrolled in adults (aged 17 and over) on a MART regimen with a low
maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate
maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS
and a LABA, with a SABA as a reliever therapy).
If asthma is uncontrolled in adults (aged 17 and over) on a moderate maintenance ICS dose
with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:
increasing the ICS to a high maintenance dose (this should only be offered as part of a
fixed-dose regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or
theophylline) or
seeking advice from a healthcare professional with expertise in asthma.
Inhaled corticosteroids and long-acting beta-2 agonists for person aged 12 or over
corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and
over.
ICS is considered appropriate, the least costly product that is suitable for an individual, within its
marketing authorisation, is recommended.
ICS and LABA is considered appropriate, the following apply.

option.
individual is recommended.

chronic asthma in adults and in children aged 12 years and over.
Evidence summaries
NICE has published evidence summaries on:
asthma in adults: beclometasone/formoterol dry powder inhaler (Fostair NEXThaler)

asthma: fluticasone furoate/vilanterol (Relvar Ellipta) combination inhaler
asthma: beclometasone/formoterol (Fostair) for maintenance and reliever treatment
asthma: fluticasone/formoterol (Flutiform) combination inhaler.
7 Inhaler devices
NICE has published a medtech innovation briefing on Smartinhaler for asthma.
Under 5s
The following recommendations are from NICE technology appraisal guidance on the use of
inhaler systems (devices) in children under the age of 5 years with chronic asthma.
For children under the age of 5 years with chronic stable asthma both corticosteroids and
bronchodilator therapy should be routinely delivered by pMDI and spacer system, with a
facemask where necessary.
Where this combination is not clinically effective for the child and depending on the child's
condition, nebulised therapy may be considered and in the case of children aged 3 to 5 years, a
DPI may also be considered.
Choice of device to be made within the pMDI and spacer range should be primarily governed by
specific individual need and the likelihood of good compliance. Once these factors have been
taken into account, choice should be made on the basis of cost minimisation.
NICE has written information for the public on the use of inhaler systems (devices) in children
under the age of 5 years with chronic asthma.
Person aged 5-15
The following recommendations are from NICE technology appraisal guidance on inhaler
devices for routine treatment of chronic asthma in older children (aged 5–15 years).
It is recommended that in addition to therapeutic need (including chosen drug and dose), the
following factors be taken into account when choosing inhaler devices for individual children
with chronic asthma:
the ability of the child to develop and maintain an effective technique with the specific
device
the suitability of a device for the child's and carer's lifestyles, considering factors such as
portability and convenience
the child's preference for and willingness to use a particular device.
The general recommendations above should be taken into account when considering the
following specific guidance:
A press-and-breathe pMDI and suitable spacer device is recommended as the first-line

choice for the delivery of inhaled corticosteroids as part of regular planned daily therapy,
with the aim of maximising benefits of preventive therapy in attaining good asthma control,
and minimising potential systemic absorption. Where clinicians believe that an individual
child's adherence to the press-and-breathe pMDI and spacer combination is likely to be so

poor as to undermine effective asthma control, other alternative devices (taking account of
evidence of equivalence of clinical effectiveness) should be considered, bearing in mind the
need to minimise the risks of systemic absorption of corticosteroids.
In the case of other inhaled drugs, primarily bronchodilators, it is recommended that a wider
range of devices be considered to take account of their more frequent spontaneous use,
the greater need for portability, and the clear feedback that symptom response provides to
the device user. In such circumstances the factors outlined above are likely to be of greater
importance in choosing a device.
Where more than one device satisfies the considerations outlined above in a particular
child, it is recommended that the device with the lowest overall cost (taking into account
daily required dose and product price per dose) should be chosen.
On selection of an inhaler device, it is important that consideration is given to other aspects of

asthma care that influence the effective delivery of inhaled therapy, including:
individual practical training in the use of the specific device

monitoring of effective inhaler technique and adherence to therapy
regular (i.e. no less than annual) review of inhaler needs, which may change over time with
increasing age.
NICE has written information for the public on inhaler devices for routine treatment of chronic
asthma in older children (aged 5–15 years).
8 Self-management
Offer an asthma self-management package, comprising a written personalised action plan and
education, to adults, young people and children aged 5 and over with a diagnosis of asthma
(and their families or carers if appropriate).
Consider an asthma self-management package, comprising a written personalised action plan

and education, for the families or carers of children under 5 with suspected or confirmed
asthma.
Within a self-management package, offer an increased dose of ICS for 7 days to adults (aged
17 and over) who are using an ICS in a single inhaler, when asthma control deteriorates. Clearly
outline in the person's asthma action plan how and when to do this, and what to do if symptoms
do not improve. When increasing the ICS dose:
consider quadrupling the regular ICS dose

do not exceed the maximum licensed daily dose.
Within a self-management package, consider an increased dose of ICS for 7 days for children
and young people (aged 5 to 16) who are using an ICS in a single inhaler, when asthma control
deteriorates. Clearly outline in the person's asthma action plan how and when to do this, and
what to do if symptoms do not improve. When increasing ICS treatment:
consider quadrupling the regular ICS dose

do not exceed the maximum licensed daily dose.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
3. Written personalised action plans
9 Decreasing maintenance therapy
Consider decreasing maintenance therapy when a person's asthma has been controlled with
their current maintenance therapy for at least 3 months.
Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of
decreasing maintenance therapy.
When reducing maintenance therapy:
Stop or reduce dose of medicines in an order that takes into account the clinical
effectiveness when introduced, side effects and the person's preference.
Only consider stopping ICS treatment completely for people who are using low dose ICS
alone as maintenance therapy and are symptom free.
Agree with the person (or their family or carer if appropriate) how the effects of decreasing
maintenance therapy will be monitored and reviewed, including self-monitoring and a follow-up
with a healthcare professional.
Review and update the person's asthma action plan when decreasing maintenance therapy.
10 Difficult and severe asthma
Omalizumab
The following recommendations are from NICE technology appraisal guidance on omalizumab
for treating severe persistent allergic asthma.
Omalizumab is recommended as an option for treating severe persistent confirmed allergic IgE-
mediated asthma as an add-on to optimised standard therapy in people aged 6 years and older:
who need continuous or frequent treatment with oral corticosteroids (defined as 4 or more
courses in the previous year), and
only if the manufacturer makes omalizumab available with the discount agreed in the
patient access scheme.
Optimised standard therapy is defined as a full trial of and, if tolerated, documented compliance
with inhaled high-dose corticosteroids, LABA, leukotriene receptor antagonists, theophyllines,
oral corticosteroids, and smoking cessation if clinically appropriate.
People currently receiving omalizumab whose disease does not meet the criteria above should
be able to continue treatment until they and their clinician consider it appropriate to stop.
NICE has written information for the public on omalizumab.
See NICE's recommendations on smoking.
Temperature-controlled laminar airflow device
NICE has published a medtech innovation briefing on the Airsonett temperature-controlled

laminar airflow device for persistent allergic asthma.
Severe refractory eosinophilic asthma
Reslizumab
The following recommendations are from NICE technology appraisal guidance on reslizumab
for treating severe eosinophilic asthma.
Reslizumab, as an add-on therapy, is recommended as an option for the treatment of severe

eosinophilic asthma that is inadequately controlled in adults despite maintenance therapy with
high-dose inhaled corticosteroids plus another drug, only if:
the blood eosinophil count has been recorded as 400 cells per microlitre or more
the person has had 3 or more severe asthma exacerbations needing systemic
corticosteroids in the past 12 months and
the company provides reslizumab with the discount agreed in the patient access scheme.
At 12 months:
stop reslizumab if the asthma has not responded adequately or

continue reslizumab if the asthma has responded adequately and assess response each
year.
An adequate response is defined as:
a clinically meaningful reduction in the number of severe exacerbations needing systemic

corticosteroids or
a clinically significant reduction in continuous oral corticosteroid use while maintaining or
improving asthma control.
These recommendations are not intended to affect treatment with reslizumab that was started in
the NHS before this guidance was published. Adults having treatment outside these
recommendations may continue without change to the funding arrangements in place for them
before this guidance was published, until they and their NHS clinician consider it appropriate to
stop.
NICE has written information for the public on reslizumab.
Mepolizumab
The following recommendations are from NICE technology appraisal guidance on mepolizumab
for treating severe refractory eosinophilic asthma.
Mepolizumab, as an add-on to optimised standard therapy, is recommended as an option for

treating severe refractory eosinophilic asthma in adults, only if:
the blood eosinophil count is 300 cells/microlitre or more in the previous 12 months and
the person has agreed to and followed the optimised standard treatment plan and
has had 4 or more asthma exacerbations needing systemic corticosteroids in the
previous 12 months or
has had continuous oral corticosteroids of at least the equivalent of prednisolone 5

mg per day over the previous 6 months and
the company provides the drug with the discount agreed in the patient access scheme.
At 12 months of treatment:
stop mepolizumab if the asthma has not responded adequately or

continue treatment if the asthma has responded adequately and assess response each
year.
An adequate response is defined as:
at least 50% fewer asthma exacerbations needing systemic corticosteroids in those people
with 4 or more exacerbations in the previous 12 months or
a clinically significant reduction in continuous oral corticosteroid use while maintaining or
improving asthma control.
This guidance is not intended to affect the position of patients whose treatment with
mepolizumab was started within the NHS before this guidance was published. Treatment of
those patients may continue without change to whatever funding arrangements were in place
for them before this guidance was published until they and their NHS clinician consider it
appropriate to stop.
NICE has written information for the public on mepolizumab.
Bronchial thermoplasty
NICE has published interventional procedures guidance on bronchial thermoplasty for severe
asthma with special arrangements for consent, audit and clinical governance.
NICE has published a medtech innovation briefing on Alair bronchial thermoplasty system for
adults with severe difficult to control asthma.
Tiotropium
NICE has published an evidence summary on asthma: tiotropium (Spiriva Respimat).
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
11. Difficult asthma
11 Monitor and review
See Asthma/asthma overview /Monitor and review
Risk stratification is a process of categorising a population by their relative likelihood of

experiencing certain outcomes. In the context of this guideline, risk stratification involves
categorising people with asthma by their relative likelihood of experiencing negative clinical
outcomes (for example, severe exacerbations or hospitalisations). Factors including non-
adherence to asthma medicines, psychosocial problems and repeated episodes of unscheduled
care can be used to guide risk stratification. Once the population is stratified, the delivery of
care for the population can be targeted with the aim of improving the care of the strata with the
highest risk.
Uncontrolled asthma
Uncontrolled asthma describes asthma that has an impact on a person's lifestyle or restricts
their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest
tightness associated with uncontrolled asthma can significantly decrease a person's quality of
life and may lead to a medical emergency. Questionnaires are available that can be quantify
this.
This guidance uses the following pragmatic thresholds to define uncontrolled asthma:
3 or more days a week with symptoms or

3 or more days a week with required use of a SABA for symptomatic relief or
1 or more nights a week with awakening due to asthma.
Glossary
BDR
bronchodilator reversibility
DPI
dry powder inhaler
Expiratory polyphonic wheeze
(a wheeze is a continuous, whistling sound produced in the airways during breathing. It is

caused by narrowing or obstruction in the airways; an expiratory polyphonic wheeze has
multiple pitches and tones heard over different areas of the lung when the person breathes out)
FeNO
fractional exhaled nitric oxide
FEV1
forced expiratory volume in 1 second
FVC
forced vital capacity
Holiday
(any longer time away from work than usual breaks at weekends or between shifts)
ICS
inhaled corticosteroid
IgE
immunoglobulin E
LABA
long-acting beta-2 agonist
LABAs
long-acting beta-2 agonists
LTRA
leukotriene receptor antagonist
LTRAs
leukotriene receptor antagonists
MART
(maintenance and reliever therapy is a form of combined ICS and LABA treatment in which a
single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance
therapy and the relief of symptoms as required; only available for ICS and LABA combinations
in which the LABA has a fast-acting component (for example, formoterol))
Objective test to diagnose asthma
(tests carried out to help determine whether a person has asthma, the results of which are not
based on the person's symptoms, for example, tests to measure lung function or evidence of
inflammation; there is no single objective test to diagnose asthma)
PC20
provoking concentration to induce a 20% reduction in forced expiratory volume in 1 second
pMDI
pressurised metered dose inhaler
ppb
parts per billion
title: Obstructive spirometry
FEV1/FVC ratio less than 70%
SABA
short-acting beta-2 agonist
SABAs
short-acting beta-2 agonists
Suspected asthma
(suspected asthma describes a potential diagnosis of asthma based on symptoms and

response to treatment that has not yet been confirmed with objective tests)
Sources
Asthma: diagnosis, monitoring and chronic asthma management (2017) NICE guideline NG80
Reslizumab for treating severe eosinophilic asthma (2017) NICE technology appraisal guidance
479
Mepolizumab for treating severe refractory eosinophilic asthma (2017) NICE technology
appraisal guidance 431
Omalizumab for treating severe persistent allergic asthma (2013) NICE technology appraisal
guidance 278
Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12
years and over (2008) NICE technology appraisal guidance 138
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of 12 years
(2007) NICE technology appraisal guidance 131
Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years)
(2002) NICE technology appraisal guidance 38
Guidance on the use of inhaler systems (devices) in children under the age of 5 years with
chronic asthma (2000) NICE technology appraisal guidance 10
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.


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Managing asthma

NICE Pathways bring together everything NICE says on a topic in an interactive

1 Person with suspected or confirmed asthma

at any asthma review, either routine or unscheduled

Doses of inhaled corticosteroids

The following definitions can be used to guide doses of ICSs.

For adults aged 17 and over:

For children and young people aged 16 and under:

less than or equal to 200 micrograms budesonide or equivalent would be considered a

If suspected asthma is uncontrolled in children under 5 on a paediatric low dose of ICS as

See principles of care [See page 3] for information on ICS doses.

The following recommendation is an extract from NICE technology appraisal guidance on

This recommendation should be read in conjunction with the recommendations in inhaler

See principles of care [See page 3] for information on ICS doses.

Inhaled corticosteroids and long-acting beta-2 agonists

The use of a combination device within its marketing authorisation is recommended as an

These recommendation should be read in conjunction with the recommendations in inhaler

Person aged 12 or over

The use of a combination device within its marketing authorisation is recommended as an

These recommendation should be read in conjunction with the recommendations in inhaler

6 Person aged 17 or over

discuss with the person whether or not to continue LTRA treatment

See principles of care [See page 3] for information on ICS doses.

The use of a combination device within its marketing authorisation is recommended as an

These recommendation should be read in conjunction with the recommendations in inhaler

NICE has published evidence summaries on:

asthma in adults: beclometasone/formoterol dry powder inhaler (Fostair NEXThaler)

NICE has published a medtech innovation briefing on Smartinhaler for asthma.

Person aged 5-15

A press-and-breathe pMDI and suitable spacer device is recommended as the first-line

child's adherence to the press-and-breathe pMDI and spacer combination is likely to be so

On selection of an inhaler device, it is important that consideration is given to other aspects of

individual practical training in the use of the specific device

Consider an asthma self-management package, comprising a written personalised action plan

consider quadrupling the regular ICS dose

consider quadrupling the regular ICS dose

See principles of care [See page 3] for information on ICS doses.

3. Written personalised action plans

9 Decreasing maintenance therapy

When reducing maintenance therapy:

See principles of care [See page 3] for information on ICS doses.

10 Difficult and severe asthma

NICE has written information for the public on omalizumab.

See NICE's recommendations on smoking.

Temperature-controlled laminar airflow device

NICE has published a medtech innovation briefing on the Airsonett temperature-controlled

Severe refractory eosinophilic asthma

Reslizumab, as an add-on therapy, is recommended as an option for the treatment of severe

stop reslizumab if the asthma has not responded adequately or

An adequate response is defined as:

a clinically meaningful reduction in the number of severe exacerbations needing systemic

NICE has written information for the public on reslizumab.

Mepolizumab, as an add-on to optimised standard therapy, is recommended as an option for

has had continuous oral corticosteroids of at least the equivalent of prednisolone 5

stop mepolizumab if the asthma has not responded adequately or

An adequate response is defined as:

NICE has written information for the public on mepolizumab.

NICE has published an evidence summary on asthma: tiotropium (Spiriva Respimat).

11. Difficult asthma

11 Monitor and review

See Asthma/asthma overview /Monitor and review

Risk stratification is a process of categorising a population by their relative likelihood of