• Clinical recommendations are to review patients that are taking three or more reliever inhalers annually. However, the clinical and patient consensus was to prioritise those prescribed six or more reliever inhalers annually. This is a trigger for timely, priority review. An immediate prescription may be necessary, but review should take place before authorisation of the next prescription.
• Review patients on SABA inhalers alone, clarifying the diagnosis and establishing reasons for SABA only use.
• Review patients with asthma prescribed SABA and LABA without ICS.
• Review patients with asthma who have been prescribed an ICS inhaler and do not currently order on their repeat prescription - assess adherence and understanding of treatment to establish appropriate use of SABA inhalers.
• Review inappropriate use of high strength corticosteroid inhalers (maintaining patients at the lowest possible dose of inhaled corticosteroid).
• Reductions in high dose ICS should be considered every three months, decreasing the dose by approximately 25 to 50% each time and arranging regular review as treatment is reduced.
• Issue a steroid treatment card to patients on inhaled high dose corticosteroids – a steroid emergency card may also be required.
• Review montelukast at four to eight weeks following initiation to ensure a response and that therapy is still required.

• Identify patients at risk of severe asthma and where modifiable risk factors are addressed and asthma control remains suboptimal, refer to secondary care for treatment optimisation.

This guidance is not for children, therefore prescribers should refer to guidance on asthma management in children, however, there are two medication safety points to highlight:

• Recommendation for regular growth monitoring when treating children with ICS. 
• Ensure children on medium / high-dose ICS are under the care of a specialist paediatrician.