Red Flags
- Acute severe asthma — PEFR <50% best, unable to complete sentences, RR ≥25, HR ≥110 — high-flow oxygen, nebulised salbutamol, IV magnesium, oral steroids, ICU consideration[1]
- Life-threatening asthma — silent chest, exhaustion, cyanosis, hypotension, altered consciousness, normal/raised pCO₂ — immediate ICU; consider intubation[1]
- Near-fatal asthma episode history — high mortality risk; specialist referral and biologic candidacy assessment[1]
- SABA-only therapy without ICS controller — strongly discouraged per GINA 2019+; high mortality risk[1]
First-line treatment
Interventions
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Budesonide-formoterol (MART/SMART)[1] | ICS-formoterol single inhaler — controller AND reliever | Budesonide-formoterol 200/6 DPI 1 puff BD plus 1 puff PRN as reliever (max 8 puffs/day) | ≥12 years: same as adult; 6–11 years: lower-dose regimen | Default Track 1 across steps 1–5; replaces SABA-only therapy |
| Medium-dose budesonide-formoterol (Track 1 step-up)[1] | Higher-dose ICS-formoterol | Budesonide-formoterol 400/12 DPI 1 puff BD with same as-needed reliever | — | Step 4 — uncontrolled on low-dose MART |
| ICS-LABA + LAMA (triple inhaler)[1] | Triple combination | Mometasone-indacaterol-glycopyrronium 160/150/50 mcg DPI once daily; or budesonide-formoterol-glycopyrronium combination | — | Step 5 — add LAMA when uncontrolled on medium-dose ICS-LABA |
| Mepolizumab, benralizumab, or dupilumab (biologics)[1] | Monoclonal antibody (anti-IL-5/IL-5R/IL-4R) | Mepolizumab 100 mg SC q4w; benralizumab 30 mg SC q4w × 3 then q8w; dupilumab 200–300 mg SC q2w | Per package by age | Severe asthma with eosinophilic phenotype despite optimised inhalers; specialist |
| Prednisolone (acute exacerbation)[1] | Oral glucocorticoid | 40–50 mg PO once daily × 5–7 days; no taper at this duration | 1–2 mg/kg/day max 40 mg × 3–5 days | Acute exacerbation; reduces relapse and accelerates recovery |
Budesonide-formoterol (MART/SMART)[1]
ICS-formoterol single inhaler — controller AND reliever
- Adult
- Budesonide-formoterol 200/6 DPI 1 puff BD plus 1 puff PRN as reliever (max 8 puffs/day)
- Paediatric
- ≥12 years: same as adult; 6–11 years: lower-dose regimen
Default Track 1 across steps 1–5; replaces SABA-only therapy
Medium-dose budesonide-formoterol (Track 1 step-up)[1]
Higher-dose ICS-formoterol
- Adult
- Budesonide-formoterol 400/12 DPI 1 puff BD with same as-needed reliever
- Paediatric
- —
Step 4 — uncontrolled on low-dose MART
ICS-LABA + LAMA (triple inhaler)[1]
Triple combination
- Adult
- Mometasone-indacaterol-glycopyrronium 160/150/50 mcg DPI once daily; or budesonide-formoterol-glycopyrronium combination
- Paediatric
- —
Step 5 — add LAMA when uncontrolled on medium-dose ICS-LABA
Mepolizumab, benralizumab, or dupilumab (biologics)[1]
Monoclonal antibody (anti-IL-5/IL-5R/IL-4R)
- Adult
- Mepolizumab 100 mg SC q4w; benralizumab 30 mg SC q4w × 3 then q8w; dupilumab 200–300 mg SC q2w
- Paediatric
- Per package by age
Severe asthma with eosinophilic phenotype despite optimised inhalers; specialist
Prednisolone (acute exacerbation)[1]
Oral glucocorticoid
- Adult
- 40–50 mg PO once daily × 5–7 days; no taper at this duration
- Paediatric
- 1–2 mg/kg/day max 40 mg × 3–5 days
Acute exacerbation; reduces relapse and accelerates recovery
Safety-net
- Use ICS-formoterol every day even when feeling well — it prevents flares; rescue-only therapy is not enough[1]
- Using rescue inhaler more than 3 times a week or waking at night — your asthma is not controlled; review needed[1]
- Severe breathlessness, blue lips, unable to talk in sentences, no response to rescue inhaler — call emergency services immediately[1]
Referral criteria
Clinical summary
Diagnosis, severity-driven stepped therapy, and exacerbation management of asthma per the GINA Strategy — single inhaler MART approach as default.