British guideline on the management of asthma in adults (continued)

Non-pharmacological management

Parents and parents-to-be who smoke should be advised of the many adverse effects of smoking on their children, including increased wheezing in infancy and increased risk of persistent asthma

Weight reduction is recommended in obese patients with asthma to promote general health and to improve asthma control

In committed families, with evidence of house dust mite allergy, multiple approaches to reduce exposure to house dust mite may help
Parents who smoke and who have asthma should be advised about the dangers to themselves and their children with asthma and offered appropriate support to stop smoking
Immunotherapy can be considered in patients with asthma where a clinically significant allergen cannot be avoided. The potential for severe allergic reactions to the therapy must be fully discussed with patients

Buteyko breathing technique may be considered to help patients to control the symptoms of asthma
Air ionisers are not recommended for the treatment of asthma

Start treatment at the step most appropriate to initial severity
Achieve early control
Maintain control by:
- stepping up treatment as necessary
- stepping down when control is good
Before initiating a new drug therapy practitioners should check compliance with existing therapies, and inhaler technique, and eliminate trigger factors
Until May 2009 all doses of inhaled steroids in this section have been referenced against beclometasone (BDP) given via CFC-MDIs (metered dose inhaler). As BDP CFC is phased out, the reference inhaled steroid will be the BDP-HFA equivalent, which can be used at the same dosage. Adjustments to doses will have to be made for other devices and other corticosteroid molecules

In selected adult patients at step 3 who are poorly controlled or in selected adult patients at step 2 (above BDP 400 µg/day who are poorly controlled), the use of budesonide/formoterol in a single inhaler as rescue medication instead of a short-acting β₂ agonist, in addition to its regular use as controller therapy has been shown to be an effective treatment regime
When this management option is introduced the total regular dose of daily inhaled corticosteroids should not be decreased. The regular maintenance dose of inhaled steroids may be budesonide 200 µg twice daily or budesonide 400 µg twice daily
Patients taking rescue budesonide/formoterol once a day or more should have their treatment reviewed. Careful education of patients about the specific issues around this management strategy is required

Regular review of patients should be carried out as treatment is stepped down. When deciding which drug to step down first and at what rate, the severity of asthma, the side-effects of the treatment, the beneficial effect achieved, and the patient’s preference should all be taken into account
Patients should be maintained at the lowest possible dose of inhaled steroid
- reduction in inhaled steroid dose should be slow as patients deteriorate at different rates
- reductions should be considered every three months, decreasing the dose by approximately 25–50% each time

For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled steroids should be reviewed
If exercise is a specific problem in patients taking inhaled steroids who are otherwise well controlled, consider the following therapies:
- leukotriene receptor antagonists
- long-acting β₂-agonists
- chromones
- oral β₂-agonists
- theophyllines
Immediately prior to exercise, inhaled short-acting β₂-agonists are the drug of choice