Ep 153 – Asthma treatment, monitoring and self-management: what's changed in the 2024 BTS, NICE and SIGN guideline?

In this episode, Dr Hannah Rosa continues looking at the new asthma guideline from the British Thoracic Society (BTS), NICE and SIGN, which was published in 2024. This guideline, based on the latest research, contains some big changes, which will hopefully help you to improve the lives of your patients living with asthma. In the first episode in the series (episode 146), Dr Rosa covered suspected asthma, asthma diagnosis and treatment in people aged 12 and over. In this second episode, she focuses on pharmacological treatment in children aged 11 and under, as well as monitoring asthma control and self-management.

Key take-home points

• All patients with asthma should be reviewed 8–12 weeks after starting or adjusting any medication.
• Uncontrolled asthma refers to any exacerbation requiring oral corticosteroids or frequent regular symptoms (such as using a reliever inhaler 3 or more days a week or night-time waking due to asthma 1 or more nights a week).
• When seeing a patient with uncontrolled asthma, before starting or adjusting medication, try to address any possible reasons that might be causing it (for example, environmental triggers).

Pharmacological management for children aged 5–11:

• Step 1 is to offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS) with short-acting beta-agonist (SABA) as needed.
• If asthma is still uncontrolled, then assess the child’s ability to manage a maintenance and reliever therapy (MART) regimen.
• If going down the MART route:
  • Consider stopping ICS and SABA and switching to a paediatric low-dose MART inhaler.
  • If asthma is still uncontrolled, then consider increasing to a paediatric moderate-dose MART.
  • If asthma is still uncontrolled, the final step is to refer the child to a specialist in asthma care.
• For children who cannot manage a MART regimen, continue their SABA inhaler and:
  • Continue their ICS and consider adding in a leukotriene receptor antagonist (LTRA), such as montelukast, for a trial period of 8–12 weeks. The LTRA should be stopped if it has been ineffective or if it has caused side effects.
  • If asthma is still uncontrolled, offer to switch the ICS to a twice-daily paediatric low-dose combination inhaler containing an ICS and a long-acting beta-2 agonist (LABA), with or without LTRA.
  • If asthma remains uncontrolled, then offer a twice-daily paediatric moderate-dose combination inhaler containing an ICS and LABA, again with or without LTRA.
  • If asthma is still uncontrolled, the final step is to refer the child to a specialist in asthma care.

Pharmacological management for children under 5:

• Consider an 8–12-week trial of a twice-daily paediatric low-dose ICS, alongside a SABA inhaler, if it is suspected that they have asthma and either of the following:
  • Symptoms that indicate the need for maintenance therapy, for example, interval symptoms (such as a persistent cough which is worse at night) alongside another atopic disorder (such as hay fever, eczema, allergic asthma or other specific and non-specific allergic conditions such as a food allergy).
  • Severe acute episodes of difficulty breathing and wheezing (for example, requiring admission to hospital or two or more courses of oral corticosteroids).
• If the child’s symptoms do not resolve after an 8–12-week trial of a twice-daily paediatric low-dose ICS, then:
  • Check inhaler technique and adherence, enquire as to whether there is an environmental source triggering symptoms and review if an alternative diagnosis is likely.
  • If none of these reasons can explain why the treatment has not worked, refer the child to a specialist in asthma care.
• If symptoms do resolve during the 8–12-week trial with the paediatric low-dose ICS:
  • Consider stopping the ICS and SABA treatment, and review the symptoms again after a further 3 months.
  • If symptoms recur or there is an acute episode that requires systemic corticosteroids or hospitalisation, restart the SABA inhaler and the regular ICS, beginning with a paediatric low-dose ICS and titrating up to a paediatric moderate-dose ICS if needed.
  • Consider a further trial without treatment after reviewing the child within 12 months.
  • If asthma is then uncontrolled, consider an LTRA in addition to ICS and SABA for a trial of 8–12 weeks, stopping it if it is ineffective or side effects develop.
  • If the asthma is still uncontrolled, stop the LTRA and refer the child to a specialist in asthma care.

Monitoring asthma control:

• Consider using a symptom questionnaire, such as the Asthma Control Test.
• Consider fractional exhaled nitric oxide monitoring for adults with asthma at their regular review and before and after changing asthma therapy.

Self-management:

• Everyone with a diagnosis of asthma should be offered a personalised action plan and self-management education.
• People aged 17 and over who are using an ICS in a single inhaler should be given advice on increasing the dose of their ICS for 7 days if their asthma control deteriorates. This may be by quadrupling the regular ICS dose, as long as doing so does not exceed the maximum licensed daily dose.

Key references

1. NICE. 2024. https://www.nice.org.uk/guidance/ng245.
2. NICE. 2017. https://www.nice.org.uk/guidance/ng80.
3. NHS Dumfries and Galloway. 2025. https://rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/respiratory/asthma-treatment-for-5-11s/.
4. NHS Dumfries and Galloway. 2025. https://rightdecisions.scot.nhs.uk/dgrefhelp-nhs-dumfries-galloway/respiratory/asthma-treatment-for-under-5s/.
5. GOV.UK. 2024. https://www.gov.uk/drug-safety-update/montelukast-reminder-of-the-risk-of-neuropsychiatric-reactions.
6. The Asthma Control Test. 2024. https://www.asthmacontroltest.com/.
7. Asthma and Lung UK; Child Asthma Action Plan. https://cdn.shopify.com/s/files/1/0221/4446/files/Childrens_Asthma_Plan_A4_trifold_DIGITAL.pdf?v=1707827551.
8. Asthma and Lung UK; Adult Asthma Action Plan. https://cdn.shopify.com/s/files/1/0221/4446/files/Adult_Asthma_Plan_A4_trifold_DIGITAL.pdf?v=1707323842.
9. Asthma and Lung UK; MART Asthma Action Plan. https://cdn.shopify.com/s/files/1/0221/4446/files/MART_action_plan_A4_trifold_fillable_form.pdf?v=1716454273.