Types of Asthma Treatment Explained: From Blue Inhalers to Long-Term Control

Asthma Treatment Overview

Asthma treatment has two goals: rapid relief of acute symptoms, and long-term control of underlying airway inflammation. These require different types of medication:

The goal of treatment is to achieve full asthma control: no daytime symptoms, no night waking, no activity limitation, no reliever use (or use <2 times per week), normal lung function, and no exacerbations.

Step 1: Reliever Inhaler Only

Step 1 is appropriate for people with very mild, infrequent asthma symptoms (less than twice per month) and no night waking. At this step, treatment consists of a short-acting beta-2 agonist (SABA) reliever inhaler — most commonly salbutamol (Ventolin Evohaler or Salamol Easi-Breathe) — used only when symptoms occur.

Step 2: Add a Preventer Inhaler (ICS)

Step 2 involves adding a low-dose inhaled corticosteroid (ICS) preventer inhaler to your daily regimen. This is the standard approach for most people with mild persistent asthma. The preventer reduces airway inflammation over time, which reduces symptom frequency and the risk of exacerbations.

Standard low-dose ICS options include:

• Beclometasone 200mcg/day (e.g. Clenil Modulite 100mcg twice daily) — first-line, widely used
• Budesonide 200–400mcg/day (e.g. Pulmicort Turbohaler)
• Fluticasone propionate 100–200mcg/day (e.g. Flixotide Evohaler or Accuhaler)

The preventer must be taken every day, even when feeling well. It typically takes 4–8 weeks to reduce airway inflammation to its optimal level. Review response at 4–8 weeks after starting.

Step 3: Add a LABA — Combination ICS+LABA Therapy

If asthma is not adequately controlled on a low-dose ICS alone, the next step is to add a long-acting beta-2 agonist (LABA). This is most conveniently done using a combination inhaler containing both ICS and LABA. Current NICE guidelines favour using a combination inhaler that can also serve as a reliever (MART approach — see below).

Common ICS+LABA combination inhalers used at Step 3:

MART Therapy Explained

MART (Maintenance and Reliever Therapy) is an approach where a single combination ICS+LABA inhaler containing formoterol (a fast-acting, long-acting bronchodilator) is used for both daily maintenance AND as a reliever during acute symptoms.

MART is currently recommended by NICE NG245 as the preferred strategy at Step 3 for adults who have been established on ICS+LABA therapy. Key advantages of MART include:

• Automatically increases ICS dose when most needed (acute episodes) — providing anti-inflammatory cover during attacks
• Reduces the total number of inhalers needed (one device instead of two)
• Consistent evidence showing reduction in severe exacerbation rates compared to fixed-dose ICS+LABA with a separate SABA reliever
• Suitable for adults aged 18+ with prescription from a GP or specialist

Step 4: Further Add-On Therapies

If asthma remains uncontrolled at Step 3, several further options are available:

• Increase ICS dose to medium — beclometasone up to 400mcg/day; budesonide up to 800mcg/day; fluticasone propionate up to 500mcg/day
• Add a LAMA (tiotropium Spiriva Respimat) — licensed add-on for adults with symptomatic asthma on ICS+LABA
• Add montelukast — a leukotriene receptor antagonist (LTRA) taken as a daily tablet; particularly useful for allergic asthma or exercise-induced symptoms
• Add theophylline — an oral bronchodilator; useful add-on in some patients but requires blood level monitoring due to narrow therapeutic index

Step 5: High-Dose Combination and Biologic Therapies

Step 5 is reserved for patients with severe asthma not controlled at Step 4. This typically involves specialist asthma centre involvement and may include:

• High-dose ICS (beclometasone >400mcg; fluticasone >500mcg; budesonide >800mcg)
• Oral corticosteroids — the lowest effective dose, used with caution given long-term side effects
• Biologic therapies — monoclonal antibodies targeting specific inflammatory pathways in severe eosinophilic or allergic asthma (mepolizumab, benralizumab, dupilumab, tezepelumab, omalizumab)
• Bronchial thermoplasty — a bronchoscopic procedure that reduces smooth muscle mass in the airways

For a detailed guide to Step 4–5 and add-on therapies, see: Asthma Treatment Types: Part 2 — Advanced and Combination Therapies.

Stepping Up and Stepping Down

The stepwise approach is bidirectional. Treatment should be stepped up promptly when asthma is not controlled. But it is equally important to step treatment down once good control has been maintained for 3 months — this reduces the risk of side effects from long-term inhaled steroids at higher doses.

Before stepping up, always check:

• Is the patient using their inhaler correctly? (Technique errors are a leading cause of apparent treatment failure)
• Is the patient taking their preventer as prescribed?
• Are there modifiable triggers (pets, smoking, occupational exposure)?
• Is the diagnosis correct? (Not all wheeze is asthma)

Non-Pharmacological Management

Medication is the cornerstone of asthma treatment, but non-pharmacological strategies play an important role in reducing trigger exposure and supporting overall control:

• Allergen avoidance: Remove or minimise exposure to identified triggers — dust mite covers, HEPA air purifiers, avoiding pets where possible
• Smoking cessation: Smoking significantly worsens asthma control and reduces ICS effectiveness. Support is available via your GP and NHS Stop Smoking services.
• Breathing techniques: The Buteyko method and other physiotherapy-based breathing techniques have modest evidence for improving quality of life in asthma
• Vaccination: Annual flu vaccination and one-off pneumococcal vaccination are recommended for all people with asthma
• Weight management: Obesity is associated with poorer asthma control; weight loss can improve symptoms significantly
• Written asthma action plan: All patients should have a written action plan from their GP detailing what to do if symptoms worsen

For a comprehensive overview of asthma — causes, symptoms, diagnosis and all treatment options — see our complete asthma condition guide. [Pillar page — link to be activated on publication]