Stepwise maintenance treatment of adult asthma

01Purpose and principlesWhat the treatment does and how it fits into care.

The 2024 joint BTS/NICE/SIGN guideline changed the preferred UK adult pathway from SABA-led escalation to ICS/formoterol AIR and MART. The reliever now delivers anti-inflammatory treatment at the same time as rapid bronchodilation, reducing reliance on blue inhalers without preventer therapy.

A stepwise pathway is a cycle, not a one-way ladder. At each review, first decide whether symptoms are asthma, whether the device reaches the lungs, whether treatment is taken, and whether rhinitis, smoking, obesity, reflux, occupational exposure or inducible laryngeal obstruction is driving poor control.

Dose labels such as low- and moderate-dose MART refer to the maintenance ICS component. Device licences vary; the chapter gives common examples, but the exact current SmPC and formulary choice must be checked at prescribing.

Key points

Confirm asthma objectively where possible and check inhaler technique, adherence, smoking, triggers and comorbidity before every step up.
Adults and people aged 12 or over with infrequent symptoms should be offered low-dose ICS/formoterol as-needed anti-inflammatory reliever (AIR), not SABA alone.
If newly diagnosed and highly symptomatic, or presenting with a severe exacerbation, start low-dose maintenance-and-reliever therapy (MART) rather than AIR alone.
If AIR is insufficient, move to low-dose MART; if low-dose MART remains insufficient after correction of basics, trial moderate-dose MART for 8-12 weeks.
If uncontrolled on moderate-dose MART, refer to an asthma specialist rather than repeatedly adding unsupervised medicines or oral steroid courses.
AIR and MART require a fast-acting formoterol combination; not every ICS/LABA inhaler can be used as a reliever.
Prescribe by brand/device and state maintenance, as-needed and maximum doses because nominal and delivered strengths differ.
Every patient needs a personalised action plan covering daily treatment, deterioration thresholds, attack instructions and urgent help.
Review 8-12 weeks after starting or changing treatment; consider step-down after sustained control, usually reducing ICS exposure gradually with close review.
Track SABA and oral corticosteroid exposure even in people using AIR/MART; repeated rescue use or steroid courses signal excess risk and require reassessment.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

AIR-appropriate asthma

Confirmed asthma with infrequent symptoms and no current high-risk presentation. The person can understand as-needed ICS/formoterol use and has a written action plan.

Start MART rather than AIR

Regular symptoms, nocturnal waking, recent exacerbation or a newly diagnosed person presenting highly symptomatic/severe. Low-dose maintenance plus the same inhaler as reliever provides continuous and responsive ICS.

Uncontrolled asthma

Daytime symptoms, night waking, activity limitation, frequent reliever use or attacks despite prescribed treatment. Verify technique/adherence and alternative diagnoses before pharmacological escalation.

High future riskRed flag

Previous ICU/intubation, recent hospital attendance, repeated oral steroids, poor adherence, excess SABA collection, psychosocial barriers, food allergy or low lung function can confer risk even when daily symptoms seem modest.

Steroid toxicity risk

High-dose ICS, repeated oral steroid courses, osteoporosis risk, cataract/glaucoma, diabetes, adrenal suppression or infection history requires cumulative-exposure review and specialist steroid-sparing strategy.

Apparent severe asthma

Persistent poor control on high-intensity treatment may be true severe disease, but common causes are wrong diagnosis, poor technique, low adherence, smoking/exposure or untreated comorbidity; separate these before biologic assessment.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Asthma Control Test/Questionnaire plus attack historyFirst step
Why
Measure current impairment and future risk separately.
Interpretation and limitations
Record symptoms, night waking, activity, reliever doses, oral steroid courses, urgent visits and admissions; a good symptom score does not erase a near-fatal history.
02
Observed inhaler technique and adherence evidence
Why
Identify the most common reversible reasons for treatment failure.
Interpretation and limitations
Match device to inspiratory ability and dexterity; use prescription collection and dose counters with a non-judgemental discussion. Correct technique before increasing dose.
03
Spirometry or peak-flow comparison
Why
Reassess airflow and the diagnosis when control is poor or treatment changes.
Interpretation and limitations
Compare with personal baseline and symptom state. Normal lung function does not exclude risk; unexpected fixed obstruction or decline should trigger diagnostic review.
04
Blood eosinophils and FeNO when escalation/referral is considered
Why
Assess type 2 inflammation and possible adherence response in context.
Interpretation and limitations
Interpret with ICS/oral steroid timing, smoking and rhinitis. Raised values may support specialist biologic pathways; normal values do not justify stopping essential ICS.
05
Comorbidity and trigger assessment
Why
Treat drivers that inhaler escalation cannot fix.
Interpretation and limitations
Review rhinitis/polyps, reflux symptoms, obesity, anxiety/dysfunctional breathing, sleep apnoea, occupational exposure, NSAID reactions and smoking/vaping; investigate selectively.
06
Cumulative steroid safety review
Why
Prevent harm from repeated systemic and high-dose inhaled corticosteroid exposure.
Interpretation and limitations
Review courses and daily doses, BP, glucose, weight, bone and ocular risk, infection and adrenal-suppression symptoms; use a steroid card where indicated.

04Treatment approachPreparation, options, escalation and aftercare.

01Preferred pathwayAIR to MART to specialistFirst stepPreferredConfirmed asthma in an adult or person aged 12 years or over.

11. Infrequent symptoms: offer low-dose ICS/formoterol as needed (AIR), teach device use and give a personalised action plan. Do not add routine SABA to an AIR/MART plan unless a specialist-defined exception applies.
22. If AIR does not control asthma, or at diagnosis symptoms are highly symptomatic/recently exacerbating, use low-dose MART: scheduled low-dose ICS/formoterol plus the same inhaler when needed.
33. If uncontrolled, first correct technique, adherence, exposures and comorbidity; then trial moderate-dose MART for 8-12 weeks and review benefit/adverse effects.
44. If still uncontrolled on moderate-dose MART, refer for specialist assessment. Do not drift into repeated oral steroid bursts without a diagnosis/risk and steroid-sparing review.

02ReviewBefore any step upSymptoms, reliever use or exacerbations suggest inadequate control.

1Confirm that symptoms are likely asthma and ask about acute red flags; revisit objective evidence if diagnosis is weak.
2Watch the person use the inhaler, check dose counter/prescription collection, clarify the exact daily and PRN schedule, and explore affordability or routine barriers.
3Address tobacco/vaping, occupational/allergen exposure and comorbid rhinitis, reflux, obesity, sleep apnoea or inducible laryngeal obstruction.
4Agree one change, a measurable endpoint and review at 8-12 weeks; earlier if high risk or deteriorating.

03Step downReduce treatment without losing safetyGood symptom control and no recent attacks for a sustained period, with low current risk.

1Choose a stable time, review risk history and agree the change in the action plan; do not step down during infection, pregnancy instability or immediately before predictable trigger exposure.
2Reduce the ICS maintenance dose by about 25-50% at intervals around 3 months, using a licensed practical regimen; keep an ICS-containing reliever and avoid complete ICS withdrawal in adults with asthma.
3Recheck symptoms, reliever doses, attacks and lung function/PEF when useful. Restore the previous effective step promptly if control deteriorates.

04SpecialistSevere-asthma assessmentUncontrolled moderate-dose MART, repeated systemic steroids, hospital/ICU attack, diagnostic uncertainty or suspected occupational disease.

1Refer with objective diagnosis evidence, exacerbation/oral steroid history, actual inhalers/doses, adherence/technique review, spirometry and available eosinophil/FeNO results.
2Specialists reconfirm diagnosis and phenotype, optimise comorbidities and consider LAMA/triple therapy, biologics, bronchial thermoplasty in exceptional contexts or maintenance oral steroid only when alternatives are unsuitable.
3Continue ICS-containing treatment and action-plan support while awaiting review; define who manages attacks and steroid-safety surveillance.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Preferred as-needed ICS-containing reliever for many adults with mild asthma.

Budesonide/formoterol low-dose AIR (example device)

Delivered 160/4.5 micrograms per inhalation: 1 inhalation when needed; if symptoms persist after a few minutes take 1 more. Maximum 6 on one occasion; more than 8 in a day is not normally needed and up to 12/day is only for a limited period under the SmPC.

Use only a product licensed/specified for AIR. Seek urgent help if it does not relieve worsening symptoms; frequent doses require review. Rinse mouth after regular exposure and monitor tremor, palpitations and thrush.

Scheduled low-dose maintenance with the same fast-acting ICS/formoterol inhaler as reliever.

Budesonide/formoterol low-dose MART (example device)

Delivered 160/4.5 micrograms: commonly 1 inhalation twice daily (or 2 once daily) plus 1 inhalation as needed; total above 8/day is not normally needed, absolute product maximum 12/day for a limited period.

Exact dose depends on device and prescribed ICS category. Do not use a slow-onset LABA combination as reliever and do not duplicate LABA across inhalers.

Next step when low-dose MART remains uncontrolled after basics are corrected.

Moderate-dose MART

An 8-12 week trial using a regimen whose maintenance ICS component falls in the NG245 moderate-dose range; for some budesonide/formoterol devices this is 2 inhalations twice daily plus PRN doses, subject to the product maximum.

Some moderate-dose MART regimens are outside licence; verify current NICE dose table, SmPC and specialist/formulary advice. Monitor cumulative ICS effects and stop/revise if no benefit.

Possible add-on where a specialist/alternative pathway identifies likely benefit, including some allergic, exercise-related or NSAID-exacerbated patterns.

Montelukast add-on in a selected adult

10 mg orally each evening (age 15+), usually as a time-limited trial with a defined outcome.

Not a replacement for ICS. Counsel on neuropsychiatric reactions and stop/review if they occur; discontinue if no meaningful response.

LAMA add-on for selected severe asthma under specialist management.

Tiotropium Respimat specialist add-on

5 micrograms inhaled once daily, delivered as 2 puffs of 2.5 micrograms, in addition to ICS and at least one controller for licensed severe-asthma use.

Not a reliever. Use caution in narrow-angle glaucoma, urinary retention and moderate/severe renal impairment; avoid duplicate antimuscarinic therapy.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Review 8-12 weeks after initiation or any step change, sooner after an attack or if reliever use is rising.
At every review record control score, night waking, activity, exacerbations, oral steroids, urgent care and actual AIR/MART doses.
Observe technique and reconcile devices to prevent duplicate LABA, accidental SABA-only use or misunderstanding of maximum doses.
Track high-dose ICS and systemic steroid exposure; review bone, metabolic, ocular, infection and adrenal risks where relevant.
Keep the personalised action plan aligned with the exact inhaler/device and update it after every material regimen change.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

AIR is treatment, not just rescue

Every symptom-driven dose combines rapid bronchodilation with anti-inflammatory therapy. That is why an ICS/formoterol product—not any LABA/ICS—is required.

More treatment can expose less treatment

A patient prescribed moderate MART but unable to use the device may receive less lung-delivered medicine than on a correctly used lower step. Technique precedes dose.

Count attacks, not only symptoms

Previous ICU care or repeated oral steroids can justify closer follow-up and referral even when the person reports few daily symptoms.

Step-down tests the minimum effective dose

It is a planned, reversible experiment with monitoring—not treatment abandonment. Complete ICS withdrawal risks loss of protection.

Biomarkers need a treatment context

Oral or inhaled steroids can suppress eosinophils and FeNO; specialist interpretation uses historical values and exacerbation pattern, not one treated sample.

08Common pitfallsFrequent interpretation and management errors.

01
Prescribing SABA alone or leaving a legacy SABA active without explaining whether it belongs in the AIR/MART plan.
02
Using a non-formoterol ICS/LABA as an as-needed reliever.
03
Stepping up before watching inhaler technique and checking adherence.
04
Quoting a generic 'two puffs' without product strength, delivered dose, schedule or maximum.
05
Continuing an ineffective add-on indefinitely without a defined trial endpoint.
06
Repeated oral steroid bursts without severe-asthma referral and cumulative-toxicity review.