Asthma treatment for 5-11s

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway
  • Maintenance and Reliever Treatment (MART) uses the same inhaler for regular treatment and as required use - i.e., no salbutamol inhaler is prescribed.
  • Formoterol has an equivalent onset of action to salbutamol. Other LABAs can’t be used.
  • MART has been shown to be equivalent or better than traditional regimes with separate preventer. and reliever but if patients drop themselves down to reliever only then ICS/formoterol PRN only has been shown to be as effective as regular ICS, whereas salbutamol alone has been shown to increase the risk of asthma exacerbation and death.
  • MART is recommended by SIGN/BTS/NICE guidance from age 5 but there are no products with a licence for MART for age 5-11. It is recommended to use inhalers which hold a licence from age 6 for 'standard' maintenance use.

MART based regime for age 5-11

Maintenance and Reliever Treatment (MART) is recommended by NICE/SIGN/BTS guidance 2024 as the preferred regime for children aged 5 or over where they are assessed as being able to manage it.

Step 1, however, is still low dose inhaled corticosteroids (ICS) and short acting beta-agonist (SABA) - Anti-inflammatory Reliever (AIR) is not recommended for under 12s. 

Step 1 - Paediatric low dose ICS plus SABA

Initial treatment with low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Soprobec 50mcg 2 puffs BD MDI 1.66 From age 2
Budesonide Easyhaler 100mcg 1 puff BD DPI 2.65 From age 6
Pulmicort turbohaler 100mcg 1 puff BD DPI 4.27 From age 5
Clenil 50mcg 2 puffs BD MDI 2.22 From age 2
Flixotide evohaler 50mcg 1 puff BD MDI 2.72 From age 2
Flixotide accuhaler 50mcg 1 puff BD DPI 4.00 From age 5

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 2 - Paediatric low dose MART

For patients who are assessed as unable to manage MART see Preventer/Reliever regime below.

Stop ICS and Salbutamol inhalers and start MART

Directions:

1 puff BD plus 1 puff PRN. Maximum 6 puffs on any one occasion

Preparations:

Inhaler Type Monthly Cost (£) Licensing
Fobumix 80/4.5 DPI 10.75 From age 6 for maintenance use
Symbicort 100/6 DPI 14.00 From age 6 for maintenance use

 

Maximum daily dose:

8 puffs daily; up to 12 puffs short term.

Monthly cost will vary depending on PRN use.

Note no inhalers are licensed for MART use in under 12s but these inhalers are licensed for 'standard' use from age 6.

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Step 3 - Paediatric moderate dose MART

If uncontrolled on paediatric low dose MART, increase to medium dose:

Directions:

2 puffs BD plus 1 puff PRN. Maximum 6 puffs on any one occasion

Preparations:

Inhaler Type Monthly Cost (£) Licensing
Fobumix 80/4.5 DPI 21.50 From age 6 for maintenance use
Symbicort 100/6 DPI 28.00 From age 6 for maintenance use

 

Maximum daily dose:

8 puffs daily; up to 12 puffs short term.

Monthly cost will vary depending on PRN use.

Note no inhalers are licensed for MART use in under 12s but these inhalers are licensed for 'standard' use from age 6.

Formulary items in blue. Formulary items which are more environmentally friendly in green.

If still uncontrolled on paediatric moderate dose MART:

  • Review and check compliance and inhaler technique.
  • Check FeNO, if available.
  • Consider referral to specialist.

Preventer/Reliever regime for age 5-11

 

The 'standard' regime of separate preventer and reliever is still an option for children who are assessed as being unable to manage MART treatment

Step 1 - Paediatric low dose ICS plus SABA

Initial treatment with low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Soprobec 50mcg 2 puffs BD MDI 1.66 From age 2
Budesonide Easyhaler 100mcg 1 puff BD DPI 2.65 From age 6
Pulmicort turbohaler 100mcg 1 puff BD DPI 4.27 From age 5
Clenil 50mcg 2 puffs BD MDI 2.22 From age 2
Flixotide evohaler 50mcg 1 puff BD MDI 2.72 From age 4
Flixotide accuhaler 50mcg 1 puff BD DPI 4.00 From age 5

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 2 - Trial of Montelukast 4mg OD (5mg from age 6)

Give the montelukast for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective.

Step 3 - Combination LABA/Paediatric low dose ICS

Step up if uncontrolled on low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Seretide evohaler 50mcg 1 puff BD MDI 8.73 From age 5
Symbicort turbohaler 100/6 1 puff BD DPI 14.00 From age 6

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Continue Montelukast if it was beneficial

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 4 - Combination LABA/Paediatric moderate dose ICS

Step up if uncontrolled on low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Seretide evohaler 50/25 2 puffs BD MDI 17.46 From age 5
Seretide accuhaler 100/50  1 puff BD DPI 17.46 From Age 5
Symbicort 100/6 2 puffs BD DPI 28.00 From age 6

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Continue Montelukast if it was beneficial

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 5 - Refer for specialist review

If uncontrolled on combination paediatric moderate dose ICS/LABA after trial of montelukast:

  • Review and check compliance and inhaler technique.
  • Check FeNO, if available.
  • Consider referral to specialist.

Editorial Information

Last reviewed: 06/01/2025

Next review date: 06/01/2027

Author(s): Emily Kennedy, Dumfries and Galloway Respiratory Managed Clinical Network.

Version: 2

Approved By: National Guidelines