Asthma in adults

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]

Inhaler technique check at every visit^[1]
Single most cost-effective intervention; >50% of patients use inhalers incorrectly
Personalised written asthma action plan^[1]
Self-titration thresholds; trigger avoidance; annual influenza vaccination; smoking cessation

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

Acute exacerbation; reduces relapse and accelerates recovery

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]

Acute severe or life-threatening asthmaEmergency department / ICU^[1]
Uncontrolled asthma despite step 4 (medium-dose ICS-LABA-LAMA)Pulmonology for biologic candidacy and phenotyping^[1]
Occupational asthma suspicionPulmonology + occupational medicine^[1]

Diagnosis, severity-driven stepped therapy, and exacerbation management of asthma per the GINA Strategy — single inhaler MART approach as default.