Theophyllines may improve lung function and symptoms, but are associated with an increase in adverse events.⁴⁶³

Addition of short-acting anticholinergics is generally of no value.⁴⁶⁴, ⁴⁸⁶ Addition of nedocromil to ICS is of marginal benefit. ⁴⁵⁷, ⁴⁶⁵

Although there are no controlled trials, children (all ages) who are under specialist care may benefit from a trial of higher doses ICS (greater than 800 micrograms/day) before moving to use of oral steroids.

[BTS/SIGN 2019]

The aim of treatment is to control asthma using the lowest possible doses of medication.

Some patients with very severe asthma not controlled with high-dose ICS, and who have also been tried on or are still taking LABA, LTRA, tiotropium (adults only) or theophyllines, may require regular long-term steroid tablets. These patients should already be under the care of a specialist asthma service.

For the small number of patients not controlled on high-dose therapies, use daily steroid tablets in the lowest dose providing adequate control.

[BTS/SIGN 2019]

Patients requiring frequent or continuous use of oral corticosteroids should be under the care of a specialist asthma service.

[BTS/SIGN 2019]

Patients on long-term steroid tablets (for example, longer than three months) or requiring frequent courses of steroid tablets (for example three to four per year) will be at risk of systemic side effects.⁴⁶³ To prevent and treat steroid tablet induced side effects:

• blood pressure should be monitored
• urine or blood sugar and cholesterol should be checked: diabetes mellitus and hyperlipidaemia may occur
• bone mineral density should be monitored in adults. When a significant reduction occurs, treatment with a long-acting bisphosphonate should be offered. See also, SIGN 142 Management of osteoporosis and the prevention of fragility fractures⁴⁸⁷
• bone mineral density should be monitored in children >5 ⁴⁸⁸
• growth (height and weight centile) should be monitored in children
• cataracts and glaucoma may be screened for through community optometric services.

Prednisolone is the most widely used steroid for maintenance therapy in patients with chronic asthma. There is no evidence that other steroids offer an advantage.

Although popular in paediatric practice, there are no studies to show whether alternate day steroids produce fewer side effects than daily steroids. No evidence was identified to guide timing of dose or dose splitting.

Immunotherapy for asthma

Studies using both subcutaneous and sublingual allergen immunotherapy (SCIT and SLIT) have shown some benefit in reducing asthma symptoms and bronchial hyper-reactivity (BHR) in children and adults currently on a range of other preventative strategies including ICS. There are, however, few studies comparing immunotherapy with ICS or of adding immunotherapy to ICS so there is difficulty precisely defining where in asthma management this approach should sit.

Subcutaneous immunotherapy

Trials of allergen-specific immunotherapy by subcutaneous injection of increasing doses of allergen extracts have consistently demonstrated beneficial effects compared with placebo in the management of allergic asthma. Allergens included house dust mite, grass pollen, tree pollen, cat and dog allergen and moulds.

Sublingual immunotherapy

There has been increasing interest in the use of sublingual immunotherapy (SLIT), which is associated with fewer adverse reactions than subcutaneous immunotherapy.

Despite the large volume of evidence evaluating the safety and clinical effectiveness of SLIT in adults and children, heterogeneity in studies (including in doses, allergens, treatment duration, other asthma medication and presence of asthma symptoms), together with the lack of data on its long-term effectiveness and concerns about study quality, mean there is currently insufficient evidence to recommend use of SLIT in adults or children with asthma.

Sublingual immunotherapy is not licensed for use in the treatment of asthma.

Bronchial thermoplasty

The aim of bronchial thermoplasty is to reduce bronchial smooth muscle mass, thus reducing the capacity for bronchoconstriction. Currently only a few UK centres offer this treatment which has considerable cost and resource implications.

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