Asthma Treatment Types: Part 2 — Advanced and Combination Therapies
What happens when standard inhalers aren’t enough: combination and MART inhalers, LAMA, montelukast, theophylline, steroid tablets, biologic injections and bronchial thermoplasty.
Part of our asthma guide: symptoms, triggers and treatment.
Asthma attack? Get help now. Call 999 if your reliever isn’t helping, you’re too breathless to speak, eat or sleep, your breathing is getting faster, or your lips or fingertips are turning blue or grey. While you wait, sit up straight and take 1 puff of your blue reliever every 30 to 60 seconds, up to 10 puffs, through a spacer if you have one. If the ambulance hasn’t arrived after 10 minutes, repeat. Don’t complete an online consultation in an emergency.
Quick answer: Most people with asthma are controlled with inhalers, and UK guidance now starts most adults on a combination inhaler used as AIR or MART. If asthma still isn’t controlled on moderate-dose MART, your GP checks FeNO and blood eosinophils, then either refers you to a specialist or tries montelukast or a LAMA inhaler. Severe asthma clinics can offer biologic injections, which have greatly reduced the need for long-term steroid tablets.
Already prescribed an inhaler? See all our asthma inhalers online.
Order Your Usual Asthma Inhaler
Access Doctor is a GPhC-registered pharmacy (#9011198). If you’re an adult with diagnosed asthma or COPD, a pharmacist independent prescriber reviews your online consultation and supplies your usual inhaler if it’s safe, and we let your GP know. Approved before 3pm, Monday to Friday? Dispatched the same day, by Royal Mail Tracked 48, Tracked 24 or Special Delivery guaranteed by 1pm next working day: you choose. Delivery is free on orders over £40.
Start Asthma Consultation →Who our online service is for. Access Doctor supplies asthma and COPD inhalers to adults aged 18 and over who already have a diagnosis, for the same inhaler, strength and dose they’re prescribed now, and we share the consultation with your GP. We can’t diagnose asthma or start or change treatment online. Children’s inhalers are managed by their GP or asthma nurse.
Where These Treatments Fit
Our asthma inhalers guide explains relievers, preventers, combination inhalers and how UK treatment starts. In short, since November 2024 the joint NICE, BTS and SIGN guideline (NG245) says, for adults and young people aged 12 and over:
- Newly diagnosed: a low-dose steroid-and-formoterol inhaler used when needed (AIR therapy), or low-dose MART if symptoms are frequent or there’s been a severe attack
- Not controlled: low-dose MART, then moderate-dose MART
- No one with asthma should be treated with a blue (SABA) reliever on its own; the MHRA reminded prescribers of this in April 2025
This guide covers what comes next, when that isn’t enough: combination inhalers in depth, LAMA, montelukast, theophylline, steroid tablets and specialist treatments for severe asthma.
Before stepping up treatment, your GP or asthma nurse should check your inhaler technique, whether you’re taking it as prescribed, triggers you can change (such as smoking, vaping, allergens, damp and mould), and whether the diagnosis is right. Poor control is often down to how existing treatment is being used rather than a need for more medicine.
Combination ICS+LABA Inhalers in Detail
Combination inhalers contain an inhaled corticosteroid, which controls inflammation, and a long-acting beta-2 agonist, which keeps the airways open for about 12 hours (24 hours for vilanterol). Those containing formoterol can also relieve symptoms, because formoterol works within minutes; those containing salmeterol or vilanterol are taken every day only, with a separate reliever.
The main combination inhalers in the UK:
| Brand | ICS | LABA | Device | How often | MART? |
|---|---|---|---|---|---|
| Fostair 100/6 | Beclometasone (extra-fine) 100mcg | Formoterol 6mcg | Aerosol or Nexthaler | Twice daily, plus as needed if MART | Yes |
| Fostair 200/6 | Beclometasone (extra-fine) 200mcg | Formoterol 6mcg | Aerosol or Nexthaler | Twice daily | No (higher dose) |
| Symbicort 100/6 and 200/6 | Budesonide 100 or 200mcg | Formoterol 6mcg | Turbohaler | Daily, plus as needed if MART; 200/6 also as AIR | Yes |
| Symbicort 400/12 | Budesonide 400mcg | Formoterol 12mcg | Turbohaler | Twice daily | No |
| Seretide 125 Evohaler | Fluticasone propionate 125mcg | Salmeterol 25mcg | Aerosol | Twice daily | No |
| Seretide 250 Accuhaler | Fluticasone propionate 250mcg | Salmeterol 50mcg | Accuhaler | Twice daily | No |
| Relvar Ellipta 92/22 | Fluticasone furoate 92mcg | Vilanterol 22mcg | Ellipta | Once daily | No |
| DuoResp Spiromax 160/4.5 | Budesonide 160mcg | Formoterol 4.5mcg | Spiromax | Daily, plus as needed if MART | Yes |
Key principle: a LABA must never be used without an inhaled steroid in asthma. A LABA on its own is linked to a higher risk of severe and life-threatening asthma attacks. Combination inhalers make sure both are always taken together. We only supply Serevent (salmeterol) for asthma to people who also have an inhaled steroid on record.
MART: Maintenance and Reliever Therapy in Practice
MART uses one combination inhaler containing a steroid and formoterol for both a regular daily dose and extra doses when you have symptoms. It works because formoterol relieves symptoms as quickly as salbutamol and lasts much longer.
Why MART is preferred over a fixed daily combination inhaler plus a separate blue reliever:
- Every extra dose for symptoms also gives steroid, so you get more anti-inflammatory treatment exactly when asthma flares
- One inhaler instead of two, which makes it easier to stick to
- Randomised trials show fewer severe attacks than with a fixed-dose combination inhaler plus a SABA reliever
- NICE NG245 recommends MART for adults whose asthma isn’t controlled on AIR therapy, at a low dose and then a moderate dose
MART dose limits, from the product information:
- Fostair 100/6 MART: 1 puff twice a day, plus 1 puff for symptoms (another after a few minutes if they continue). No more than 8 puffs a day.
- Symbicort 100/6 or 200/6 MART: the daily dose your prescriber sets, plus 1 inhalation for symptoms (another after a few minutes if needed). No more than 6 on one occasion; normally no more than 8 a day, up to 12 for a short time.
MART inhalers must contain formoterol. Seretide contains salmeterol, which works too slowly to relieve symptoms, so it can’t be used as MART. If you need extra doses on most days, see your GP or asthma nurse.
Reliever · Rx
Ventolin Evohaler 100mcg
Salbutamol aerosol, the blue inhaler. 200 puffs. From £8.99.
View product →Reliever · Rx
Salamol 100mcg
The same medicine, salbutamol, in a different inhaler. From £13.99.
View product →Device
AeroChamber Plus adult spacer
Helps more of each puff reach your lungs. £9.99.
View product →Combination · Rx
Symbicort Turbohaler
Steroid and fast-acting reliever in one; used daily, or as AIR or MART. From £41.99.
View product →LAMA Add-On Therapy (Tiotropium)
Long-acting muscarinic antagonists (LAMAs) block muscarinic receptors in the airways, relaxing the muscle and reducing mucus. They last 24 hours and are taken once a day.
Tiotropium (Spiriva Respimat) is the LAMA licensed for asthma in the UK. It’s an add-on for people aged 6 and over with severe asthma who’ve had at least one severe attack in the past year despite an inhaled steroid and at least one other controller. NICE suggests an 8 to 12 week trial of a LAMA or montelukast if asthma isn’t controlled on moderate-dose MART and FeNO and blood eosinophils aren’t raised. Key points:
- Can reduce attacks when added to an inhaled steroid and LABA
- Adults take 2 puffs once a day (2.5 micrograms each) through the Respimat soft mist inhaler
- Side effects: dry mouth is the most common; constipation and difficulty passing urine are less common
- Use with caution if you have narrow-angle glaucoma or prostate or bladder problems
Our Atrovent inhaler contains ipratropium, a short-acting relative used mainly in COPD.
Montelukast (Leukotriene Receptor Antagonist)
Montelukast (Singulair) is a tablet taken once a day in the evening. It blocks leukotriene receptors, reducing the effect of inflammatory chemicals that narrow the airways and increase mucus. It’s a different class of medicine from steroids or bronchodilators.
Montelukast may be particularly useful for:
Allergic asthma
Leukotrienes are involved in allergic airway inflammation, and montelukast can also help hay fever symptoms when the two occur together.
Exercise-induced symptoms
It can reduce airway narrowing brought on by exercise.
Aspirin-sensitive asthma
In some people, aspirin and other anti-inflammatory painkillers (NSAIDs) trigger asthma through leukotrienes, and montelukast may help.
Mood and behaviour changes: montelukast can rarely cause neuropsychiatric side effects, such as sleep problems, nightmares, agitation, low mood and, very rarely, suicidal thoughts, in adults and children. The MHRA advises patients and carers to stop taking it and tell their prescriber straight away if these happen.
Theophylline
Theophylline is a tablet that widens the airways and has a mild anti-inflammatory effect. It belongs to a group called methylxanthines and works partly by blocking phosphodiesterase enzymes, which relaxes airway muscle.
Theophylline has a narrow therapeutic index: the difference between an effective level in the blood and a toxic one is small. Too much causes nausea, vomiting, a fast or irregular heartbeat and, in serious cases, seizures. Blood levels need checking, usually aiming for 10 to 20 mg per litre.
Because of this, it’s now rarely started and is mainly kept for people who can’t take other add-on treatments or who already benefit from it.
Interactions: some medicines raise theophylline levels, including ciprofloxacin, erythromycin and clarithromycin, and allopurinol; others lower them, including rifampicin, carbamazepine and phenytoin. Smoking lowers levels, so stopping smoking can raise them. Always tell a prescriber or pharmacist that you take it.
Oral Corticosteroids
Steroid tablets (usually prednisolone) are used in asthma in two ways:
- Short courses for an asthma attack: usually 40 to 50mg a day for at least 5 days in adults. They calm a flare-up quickly and reduce the risk of it coming back. Short courses have few side effects, but needing them more than once or twice a year means asthma needs a review.
- Long-term steroid tablets: used only in severe asthma under specialist care, at the lowest dose that works. People on them are monitored for bone thinning, diabetes, high blood pressure, cataracts and adrenal suppression, and may need bone protection treatment.
Long-term steroid tablets carry significant risks, including osteoporosis, diabetes, high blood pressure, adrenal suppression, cataracts, weight gain and infections. Never stop them suddenly after long-term use. Biologic treatments have greatly reduced the need for them in severe asthma, so people on them should be assessed by a severe asthma service.
Biologic Therapies for Severe Asthma
Biologics are injections of monoclonal antibodies that block specific molecules driving inflammation in severe asthma. For people with severe asthma that isn’t controlled despite high-dose treatment, they’ve been a major advance, and many people have been able to cut down or stop steroid tablets.
Biologics approved for asthma in the UK:
| Drug (brand) | Target | Asthma type | How it’s given |
|---|---|---|---|
| Mepolizumab (Nucala) | IL-5 | Severe eosinophilic asthma | Injection every 4 weeks |
| Benralizumab (Fasenra) | IL-5 receptor | Severe eosinophilic asthma | Injection every 4 weeks for the first 3 doses, then every 8 weeks |
| Dupilumab (Dupixent) | IL-4 receptor (blocks IL-4 and IL-13) | Severe asthma with raised eosinophils and FeNO | Injection every 2 weeks |
| Tezepelumab (Tezspire) | TSLP | Severe asthma, including people without raised eosinophils | Injection every 4 weeks |
| Omalizumab (Xolair) | IgE | Severe allergic (IgE-driven) asthma | Injection every 2 or 4 weeks |
Biologics are started and supervised by specialist severe asthma services. Each has NICE criteria, based on things like blood eosinophil count, FeNO, IgE level, how many attacks needed steroid tablets in the past year, and whether you take steroid tablets every day. Response is reviewed at set points, which differ between medicines (from about 16 weeks to 12 months), and treatment continues only if it’s clearly helping.
Biologics can transform severe asthma. In people who respond, they reduce attacks and the need for steroid tablets. If your asthma isn’t controlled on high-dose inhaled treatment, or you need steroid tablets often, ask your GP about referral to a specialist asthma service.
Bronchial Thermoplasty
Bronchial thermoplasty is a procedure, not a medicine, for adults with severe asthma that isn’t controlled despite the best medical treatment. Through a bronchoscope (a thin camera passed into the airways), controlled heat is applied to the airway walls to reduce the layer of smooth muscle.
With less muscle, the airways can’t narrow as much when triggered. It’s done in three sessions, a few weeks apart, each treating a different part of the lungs. Asthma can get worse for a short time after each session.
NICE says it should only be done with special arrangements for consent and audit, in specialist centres, for a small, carefully chosen group of people. Longer-term studies have reported fewer attacks for some people, but it’s used far less now that biologics are available.
The Stepwise Approach Revisited
Whatever the treatment, decisions follow the same review cycle:
1
Assess control and look for reasons
Check inhaler technique at every review, whether treatment is being taken as prescribed, triggers you can change (smoking, vaping, allergens, damp and mould, work exposures), other conditions, and whether the diagnosis is right.
2
Step up if asthma isn’t controlled
Under NICE NG245: AIR → low-dose MART → moderate-dose MART → check FeNO and blood eosinophils → specialist referral if either is raised, or an 8 to 12 week trial of montelukast or a LAMA if not → specialist referral if still uncontrolled.
3
Step down once asthma is controlled
When asthma has been well controlled, usually for at least 3 months, your GP or asthma nurse will consider reducing treatment to the lowest dose that keeps it controlled. This is done one change at a time, with a review after each, never by stopping a preventer yourself.
Safety, your GP and free NHS options
Asthma inhalers are prescription-only medicines in the UK. Before anything is supplied, a GPhC-registered pharmacist independent prescriber reviews your consultation, including the other medicines you take; some, such as beta-blockers, can make asthma worse.
- Relievers on their own: since 2024, UK guidance (NICE, BTS and SIGN) says adults with asthma shouldn’t be treated with a reliever alone, and in April 2025 the MHRA reminded prescribers not to supply one without an inhaled steroid. If you don’t use a preventer, we can supply a reliever once and will ask you to see your GP or asthma nurse.
- How many: up to 2 reliever inhalers per order. If you’ve needed 3 or more in the last 12 months, we’ll ask you to have an asthma review first; needing that many is linked to a higher risk of severe attacks.
- Read the leaflet in the pack, and ask a pharmacist or asthma nurse to check your technique.
- Report side effects to a pharmacist or doctor. You can also report them to the MHRA through the Yellow Card scheme.
We share your consultation with your GP because asthma needs ongoing care. Access Doctor is a private service, and there are free NHS options:
- Your GP practice: asthma reviews (at least once a year) and repeat prescriptions; many practices let you order repeats through the NHS App.
- Prescription charges: NHS prescriptions are free in Scotland, Wales and Northern Ireland. In England a charge applies unless you’re exempt, and a prepayment certificate can save money if you need several items.
- Urgent advice: NHS 111 (NHS 24 on 111 in Scotland), or 999 in an emergency.
Need Your Usual Inhaler?
Access Doctor is a GPhC-registered pharmacy (#9011198). If you’re an adult with diagnosed asthma or COPD, a pharmacist independent prescriber reviews your online consultation and supplies your usual inhaler if it’s safe, and we let your GP know. Approved before 3pm, Monday to Friday? Dispatched the same day, by Royal Mail Tracked 48, Tracked 24 or Special Delivery guaranteed by 1pm next working day: you choose. Delivery is free on orders over £40.
Start Asthma Consultation →Frequently Asked Questions
What are combination inhalers for asthma?
Combination inhalers contain an inhaled steroid (ICS) and a long-acting bronchodilator (LABA) in one device. Examples include Symbicort (budesonide and formoterol), Fostair (beclometasone and formoterol), Seretide (fluticasone and salmeterol) and Relvar Ellipta (fluticasone furoate and vilanterol). Those containing formoterol can also be used as a reliever (AIR or MART) when prescribed that way. UK guidance now uses them as the first treatment for most adults. Our asthma inhalers guide compares them.
What are biologic therapies for asthma?
Biologics are injections of antibodies that block one specific part of the inflammation in severe asthma. The ones used in the UK are mepolizumab (Nucala), benralizumab (Fasenra), dupilumab (Dupixent), tezepelumab (Tezspire) and omalizumab (Xolair). They’re for people with severe asthma that isn’t controlled on high-dose inhaled treatment, or who need frequent steroid tablets, and they’re started and monitored by specialist severe asthma services. For people who respond, they can reduce attacks and the need for steroid tablets.
What is montelukast used for in asthma?
Montelukast is a leukotriene receptor antagonist taken as a tablet once a day. It blocks leukotrienes, chemicals that narrow the airways and increase mucus. NICE suggests trying it, or a LAMA inhaler, for 8 to 12 weeks if asthma isn’t controlled on moderate-dose MART and tests don’t point to a specialist referral. It can help when asthma comes with hay fever or exercise symptoms. It carries an MHRA warning about mood, behaviour and sleep changes; tell your prescriber about any.
What is theophylline used for in asthma?
Theophylline is an older bronchodilator tablet, sometimes used as an add-on in difficult-to-control asthma. The gap between an effective and a toxic level is small, so it needs blood tests, and many common medicines and smoking change its level. Side effects such as nausea, a fast heartbeat and poor sleep are common if the level is too high. It’s rarely started now because better-tolerated options exist.
How do I know if I have severe asthma?
Severe asthma means asthma that stays uncontrolled despite high-dose treatment taken correctly, or that only stays controlled on that treatment. Signs include frequent symptoms, needing steroid tablets for attacks more than once or twice a year, or hospital visits. Before deciding asthma is severe, your GP should check your technique, how you take your inhalers, your triggers and the diagnosis. If it’s still uncontrolled, ask about referral to a severe asthma service. Our asthma diagnosis guide covers the tests.
For symptoms, triggers and how asthma is diagnosed, see our asthma guide.
References
- NICE, BTS and SIGN. Asthma: diagnosis, monitoring and chronic asthma management (NG245), November 2024. nice.org.uk
- NICE, BTS and SIGN. Pharmacological management of asthma in people aged 12 and over (NG245 algorithm), November 2024. sign.ac.uk
- MHRA Drug Safety Update. Short-acting beta-2 agonists (SABA): reminder of the risks from overuse in asthma and changes in the SABA prescribing guidelines, April 2025. gov.uk
- Electronic Medicines Compendium. Fostair 100/6 micrograms pressurised inhalation solution: Summary of Product Characteristics. medicines.org.uk
- Electronic Medicines Compendium. Spiriva Respimat 2.5 micrograms solution for inhalation: Summary of Product Characteristics. medicines.org.uk
- NHS. Asthma: treatment. nhs.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.