Asthma treatment for age 12 and over

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway
  • Maintenance and Reliever Treatment (MART) and Anti-inflammatory Reliever (AIR) treatment 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.
  • PRN only dosage of ICS/formoterol is now licensed in the UK as AIR.  It is used widely worldwide and recommended by current NICE/SIGN/BTS Guideline 2024.
  • AIR is only recommended for age 12 and over (Symbicort 200/6, WockAIR 160/4.5 and DuoResp Spiromax 160/4.5 are all licensed inhalers for AIR from age 12).  

Step 1 - Anti-inflammatory Reliever (AIR) therapy

Initial treatment step for mild symptoms

Directions:

1 puff PRN. Maximum 6 puffs on any one occasion

Preparations:

Inhaler Type Cost per 120 doses (£) Licensing
Symbicort Turbohaler 200/6 DPI 28.00 From age 12
Duoresp Spiromax 160/4.5 DPI 27.97 From age 12
WockAIR 160/4.5 DPI 19.00 From age 12

 

Maximum daily dose:

8 puffs daily; up to 12 puffs short term.

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

Step 2 - Low dose MART

Initial treatment step for severe symptoms or step up if uncontrolled on AIR

Directions:

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

Preparations:

Inhaler Type Monthly Cost (£) Licensing
Fobumix 160/4.5 DPI 10.75 From age 12
Duoresp 160/4.5 DPI 13.99 From age 12
WockAIR 160/4.5 DPI 9.50 From age 12
Symbicort 200/6 DPI 14.00 From age 12
Fostair 100/6 MDI 14.66 From age 18
Luforbec 100/6 MDI 6.99 From age 18
Bibecfo 100/6 MDI 6.99 From age 18
Fostair 100/6 Nexthaler DPI 14.66 From age 18

 

Maximum daily dose:

8 puffs daily; up to 12 puffs short term.

Monthly cost will vary depending on PRN use.

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

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

Step 3 - Moderate dose MART

Step up if uncontrolled on low dose MART

Directions:

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

Preparations:

Inhaler Type Monthly Cost (£) Licensing
Fobumix 160/4.5 DPI 21.50 From age 12
Duoresp 160/4.5 DPI 27.97 From age 12
WockAIR 160/4.5 DPI 19.00 From age 12
Symbicort 200/6 DPI 28.00 From age 12
Fostair 100/6 MDI 29.32 From age 18
Luforbec 100/6 MDI 13.98 From age 18
Bibecfo 100/6 MDI 13.98 From age 18
Fostair 100/6 Nexthaler DPI 29.32 From age 18

 

Maximum daily dose:

8 puffs daily; up to 12 puffs short term.

Monthly cost will vary depending on PRN use.

Formulary items in green.

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

Step 4 - Montelukast / LAMA or refer

If uncontrolled on moderate dose MART:

  • Review and reconsider
    • Check inhaler technique
    • Check compliance/concordance
    • Look for ongoing inflammation by testing FeNO or Eosinophil count
  • If evidence of ongoing inflammation and compliance and technique good consider specialist review
  • If FeNO/Eosinophils normal - try adding:

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