PSA Question Bank

Low-dose inhaled corticosteroid (ICS) is the recommended first step-up in asthma management per NICE NG80 when SABA use exceeds three times per week or nocturnal symptoms occur. This patient has uncontrolled asthma with frequent reliever use and night-time waking, meeting criteria for regular preventer therapy.

NICE recommends a stepwise approach: Step 1 is SABA as needed; Step 2 adds low-dose ICS (beclometasone 200–400mcg/day equivalent). If still uncontrolled, Step 3 adds a LABA to ICS, ideally as a combination inhaler. Leukotriene receptor antagonists are alternative add-on therapy at Step 3 if LABA is not tolerated or ineffective.

LABAs must never be prescribed without concomitant ICS due to the risk of increased asthma mortality demonstrated in the SMART study. Oral corticosteroids are reserved for acute exacerbations, not routine step-up. Continuing SABA monotherapy is inappropriate given the frequency of symptoms and uncontrolled disease markers.

The goal is symptom control with the lowest effective ICS dose, reviewing every two to three months and stepping down when stable for three months.

Remember: ICS is first-line preventer in asthma - never add a LABA without ICS, and step up when SABA use exceeds three times weekly per NICE NG80.

When asthma is well controlled for at least three months, NICE NG80 recommends considering a step-down in treatment, typically reducing the ICS dose by 25–50% at each step while monitoring for deterioration. Stepping down should be gradual, with review at each stage to ensure maintained control.

The recommended approach is to reduce the ICS dose first while maintaining the LABA, as ICS remains the cornerstone of asthma management. If the patient remains stable on a low-dose ICS plus LABA, the next step is to trial stopping the LABA. Complete cessation of ICS is rarely appropriate, as asthma is a chronic inflammatory condition with risk of relapse.

Stopping all inhalers abruptly risks an acute exacerbation and is never recommended. Switching directly to SABA-only loses the anti-inflammatory benefit that has maintained control. The BTS/SIGN guideline similarly advises stepwise reduction with close monitoring.

Patients should be counselled that stepping down does not mean cure - asthma requires ongoing management. They should have a personalised asthma action plan detailing how to increase treatment if symptoms worsen.

Remember: Step down asthma treatment gradually when well controlled for three months - reduce ICS dose by 25–50% and review, never stop preventer therapy abruptly per NICE NG80.

Maintenance and Reliever Therapy (MART) uses a single budesonide/formoterol inhaler for both regular maintenance and as-needed relief, recommended by NICE NG80 as an option at Step 3 and above. The rapid onset of formoterol allows it to function as a reliever, while each additional dose provides extra anti-inflammatory corticosteroid.

MART reduces exacerbation rates compared with fixed-dose ICS/LABA plus separate SABA, as shown in the SMART and STAY trials. The approach ensures patients receive additional ICS during periods of worsening control, addressing the inflammatory component. Only budesonide/formoterol combinations are licensed for MART - salmeterol-containing inhalers are not suitable due to slower onset.

This patient has suboptimal control on separate ICS and LABA with frequent reliever use, making MART an ideal rationalisation strategy. It simplifies the regimen to a single inhaler, improving adherence. Patients must be counselled to use the inhaler both regularly and as needed.

Montelukast and tiotropium are subsequent options if MART does not achieve control. Increasing ICS without optimising the delivery strategy may increase side effects without proportional benefit.

Remember: MART uses budesonide/formoterol as both preventer and reliever - it reduces exacerbations and simplifies treatment, and only formoterol-based combinations are suitable per NICE NG80.