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Poorly controlled asthma: treatment options in the current BTS/SIGN guideline. Read and reflect

Poorly controlled asthma in adults: treatment options in the current BTS/SIGN guideline.

Read and reflect

Access to this resource has been made possible by an educational grant from Boehringer Ingelheim. Boehringer Ingelheim has reviewed this module and the accompanying article for accuracy and compliance with the Association of the British Pharmaceutical Industry (ABPI) Code of Practice.


The majority of people with asthma in the UK are usually managed in primary care following the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guidelines.1 However, not all patients’ asthma is well controlled on standard monotherapies of inhaled corticosteroids (ICS) plus short-acting bronchodilator or ICS plus long-acting bronchodilators (LABA), and for some people, treatment needs to be escalated to achieve good control.2

Furthermore, the National Review of Asthma Deaths (NRAD) revealed that many of the people who died of asthma were being treated for ‘mild to moderate’ asthma,3 indicating a need for more careful consideration of diagnosis, the control (or lack of control) of symptoms and treatment options.

Until recently, the main therapy options for people with poorly controlled asthma were to increase the dose of ICS, add a long-acting beta2 agonist and to consider additional treatment options such as a leukotriene receptor antagonist, slow release theophylline or oral beta2 agonists.2 Since 2014, however, the long-acting muscarinic antagonist (LAMA) tiotropium has been licensed for the management of asthma in adults who remained poorly controlled despite using an ICS/LABA.4

This resource is offered at an advanced level. Complete the module by reading the article, Masterclass: When asthma is poorly controlled: treating asthma in adults according to the BTS/SIGN guideline, reflecting on the information and answering the questions which follow to consolidate your knowledge. Save your additional reading articles in MY FOLDERS and complete the activities/reflections, considering how this module reflects the NMC Code. On completion, you can obtain a certificate for one hour of continuing professional development to add to your revalidation portfolio.

Aims and objectives

On completion of this module, you should have an understanding of:

  • The treatment options for the management of inadequately controlled asthma according to the 2016 BTS/SIGN guideline
  • When specialist input should be sought for people with asthma
  • The ways of assessing asthma control and the definition of good asthma control
  • The evidence for the long-acting antimuscarinic antagonist tiotropium in the management of asthma that remains poorly controlled despite standard treatment with ICS/LABA

References/Further reading

1. Small I. The majority of asthma cases can be managed in primary care. Guidelines in Practice, July 2012. Available at: htttps://

2. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma, 2016

3. Royal College of Physicians. Why asthma still kills: The National Review of Asthma Deaths (NRAD), 2014

4. Spiriva Respimat 2.5 microgram, inhalation solution. Summary of Product Characteristics.

5. Robinson DS, Campbell DA, Durham SR, et al. Systematic assessment of difficult-to-treat asthma. European Respiratory Journal 2003;22(3):478-483

6. d’Ancona G. Inhaled corticosteroids: managing side effects, Pharmaceutical Journal 2015;294(7851)

7. NICE. Asthma: tiotropium (Spiriva Respimat), 2015

8. Pinnock H, Burton C, Campbell S, et al. Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study. Prim Care Respir J 2012; 21: 288-94.

9. Asthma UK. Asthma Control Test.

10. Anderson DE, Kew KM, Boyter AC. (2015) Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus the same dose of ICS alone for adults with asthma. Cochrane Review, 2015.

11. Bateman ED, Kornmann O, Schmidt P, et al. Tiotropium is noninferior to salmeterol in maintaining improved lung function in B16-Arg/Arg patients with asthma. J Allergy Clin Immunol 2011;128(2):315-22.

12. Evans DJW, Kew KM, Anderson DE, et al. Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus higher dose ICS for adults with asthma. Cochrane Review, 2015.

13. Kew KM, Dahri K. Long-acting muscarinic antagonists (LAMA) added to combination long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma. Cochrane Review 2016.

Date of preparation: January 2017                  Job Code: UK/SPRT-161042