D. Add salmeterol – Explanation
The British Thoracic Society recommend adding a long-acting B2 agonist if there is an inadequate
response to the addition of inhaled steroid. The inhaled steroid dose should be increased if there is
an inadequate response to the long-acting B2 agonist.
Asthma: stepwise management in adults
The management of stable asthma is now well established with a step-wise approach:
| Step 1 | Inhaled short-acting B2 agonist as required |
| Step 2 | Add inhaled steroid at 200-800 mcg/day* 400 mcg is an appropriate starting dose for many patients. Start at dose of inhaled steroid appropriate to severity of disease |
| Step 3 | 1. Add inhaled long-acting B2 agonist (LABA) 2. Assess control of asthma:
|
| Step 4 | Consider trials of:
|
| Step 5 | Use daily steroid tablet in lowest dose providing adequate control. Consider other treatments to minimise the use of steroid tablets Maintain high dose inhaled steroid at 2000 mcg/day* Refer patient for specialist care |
*beclometasone dipropionate or equivalent
Additional notes
Leukotriene receptor antagonists
- e.g. Montelukast, zafirlukast
- have both anti-inflammatory and bronchodilatory properties
- should be used when patients are poorly controlled on high-dose inhaled corticosteroids and a
longacting b2-agonist - particularly useful in aspirin-induced asthma
- associated with the development of Churg-Strauss syndrome
Fluticasone is more lipophilic and has a longer duration of action than beclometasone
Hydrofluoroalkane is now replacing chlorofluorocarbon as the propellant of choice. Only half the
usually dose is needed with hydrofluoroalkane due to the smaller size of the particles
Long acting B2-agonists acts as bronchodilators but also inhibit mediator release from mast cells.
Recent metaanalysis showed adding salmeterol improved symptoms compared to doubling the
inhaled steroid dose
