Personal asthma action plan

As part of your initial assessment, you should be encouraged to draw up a personal asthma action plan with your GP or asthma nurse. If you have been admitted to hospital because of an asthma attack, you should be offered an action plan (or the opportunity to review an existing action plan) before you go home.

The action plan should include information about your asthma medicines and will help you recognise when your symptoms are getting worse and what steps to take. You should also be given information about what to do if you have an asthma attack.

Your personal asthma action plan should be reviewed with your GP or asthma nurse at least once a year, or more frequently if your symptoms are severe.

As part of your asthma plan, you may be given a peak flow meter. This will give you another way of monitoring your asthma, rather than relying only on symptoms.

Want to know more?

• Your health, your way: What is self care?
• Asthma UK: Personal asthma action plan.

Taking asthma medicines

Inhalers

Asthma medicines are usually given by inhalers, which are devices that deliver the drug directly into the airways through your mouth when you breathe in. Inhaling a drug is an effective way of taking an asthma medicine as it goes straight to the lungs, with very little ending up elsewhere in the body. However, each inhaler works in a slightly different way. You should have training from your GP or nurse in how to use your device. This should be checked at least once a year.

Spacers

Some inhalers emit an aerosol jet when pressed. These work better if given through a spacer, which can increase the amount of medication that reaches the lungs and reduce the side effects. Some people find using inhalers difficult, and spacers can help them. However, spacers are often advised even for people who use inhalers well as they improve the distribution of medication in the lungs. Spacers are large plastic or metal containers with a mouthpiece at one end and a hole for the inhaler at the other. The medicine is ‘puffed’ into the spacer by the inhaler and it is then breathed in through the spacer mouthpiece. Spacers are also good for reducing the risk of thrush in the mouth or throat, which can be a side effect of inhaled asthma medicines.

Want to know more?

• Asthma UK: Using your inhalers.

Reliever inhalers

Reliever inhalers are taken to relieve asthma symptoms quickly. The inhaler usually contains a medicine called a short-acting beta2-agonist. It works by relaxing the muscles surrounding the narrowed airways. This allows the airways to open wider, making it easier to breathe again. Examples of reliever medicines include salbutamol and terbutaline. They are generally safe medicines with few side effects, unless they are over used. However, they should rarely be necessary if asthma is well controlled, and anyone needing to use them three or more times a week should have their treatment reviewed.

Everyone with asthma should be given a reliever inhaler, also known simply as a reliever. It is often blue.

Want to know more?

• Asthma UK: Relievers.

Preventer inhalers

Preventer inhalers work over time to reduce the amount of inflammation and ‘twitchiness’ in the airways and prevent asthma attacks occurring. You will need to use the preventer inhaler daily for some time before you gain the full benefit. You may still occasionally need the reliever inhaler (usually blue) to relieve symptoms, but if you continue to need them often, your treatment should be reviewed.

The preventer inhaler usually contains a medicine called an inhaled corticosteroid. Examples of preventer medicines include beclometasone, budesonide, fluticasone and mometasone. Preventer inhalers are often brown, red or orange.

Preventer treatment is normally recommended if you:

• have asthma symptoms more than twice a week
• wake up once a week due to asthma symptoms
• have to use a reliever inhaler more than twice a week

Smoking can reduce the effects of preventer inhalers.

Inhaled corticosteroids can occasionally cause a mild fungal infection (oral thrush) in the mouth and throat, so rinse your mouth thoroughly after inhaling a dose. For more information on side effects, see below.

Want to know more?

• Asthma UK: Preventer inhalers.

Other treatments and ‘add on’ therapy

Long-acting reliever inhaler

If your asthma does not respond to treatment, the dose of preventer inhaler can be increased in discussion with your healthcare team. If this does not control your asthma symptoms, you may be given an inhaler containing a medicine called a long-acting reliever (long-acting bronchodilator/long acting beta2-agonist or LABA) to take as well. Or you may be given an inhaler combining an inhaled steroid and a long-acting bronchodilator in the one device, called a ‘combination’ inhaler. These work in the same way as short-acting relievers, but they take longer to work and can last up to 12 hours. Examples of long-acting reliever inhalers include formoterol and salmeterol

Only use your long-acting reliever inhaler in combination with the preventer inhaler and never by itself. Studies have shown that using only a long-acting reliever can increase the chance of an asthma attack and can even increase the risk of death. Examples of combination inhalers include Seretide, Symbicort and Fostair. These are usually purple, red and white, or maroon.

Preventer medicines

If treatment of your asthma is still not successful, additional preventer medicines will be tried. Two possible alternatives include:

• leukotriene receptor antagonists (montelukast): tablets that block part of the chemical reaction involved in inflammation of the airways
• theophyllines: tablets that help widen the airways by relaxing the muscles around them

If your asthma is still not under control, you may be prescribed regular oral steroids (steroid tablets). This treatment is usually monitored by a respiratory specialist (a specialist in asthma). Long-term use of oral steroids has possible serious side effects, so they are only used once other treatment options have been tried. See below for more information on the side effects of steroid tablets.

Occasional use of oral steroids

Most people only need to take a course of oral steroids for one or two weeks. Once your asthma is under control, you can be 'stepped-down' to your previous treatment.

Omalizumab (Xolair)

Omalizumab, also known as Xolair, is the first of a new category of drugs. It binds to one of the proteins involved in the immune response and reduces its level in the blood. This reduces the chance of an immune reaction happening. The National Institute for Heath and Clinical Excellence (NICE) recommends that omalizumab can be used in people with severe persistent allergic asthma who meet certain criteria.

Omalizumab is given as an injection every two to four weeks. It should only be prescribed in a specialist centre. If omalizumab does not control asthma symptoms within 16 weeks, the treatment should be stopped.

Want to know more?

• Asthma UK: Other treatments and ‘add on’ therapies.
• Asthma UK: Steroid tablets.
• NICE: Omalizumab for severe persistent allergic asthma (PDF, 76Kb).

Side effects of treatments

Side effects of relievers and preventers

Relievers are a safe and effective medicine and have very few side effects, as long as they are not used too much. The main side effects include a mild shaking of the hands, headache and muscle cramps. These usually only happen with high doses of reliever inhaler and usually only last for a few minutes.

Preventers are very safe at usual doses, although they can cause a range of side effects at high doses, especially over long-term use. The main side effect of preventer inhalers is a fungal infection (oral candidiasis) of the mouth or throat. You may also develop a hoarse voice. Using a spacer can help prevent these side effects. Also, rinse your mouth or clean your teeth after taking your preventer inhaler.

Your doctor or nurse will discuss with you the need to balance the control of your asthma with the risk of side effects, and how to keep the side effects to a minimum.

Side effects of add on therapy

Long-acting relievers may cause similar side effects to short-acting relievers, including a mild shaking of the hands, headache and muscle cramps. Some studies have suggested that there may be a small increased risk of serious side effects, including severe asthma attacks and death, when using long-acting relievers with corticosteroids. Your GP can discuss the risks and benefits of this drug with you. You should be monitored at the beginning of your treatment and reviewed regularly. If you find there is no benefit to using the long-acting reliever, it should be stopped.

Theophylline tablets have been known to cause side effects in some people, including headaches, nausea, insomnia, vomiting, irritability and stomach upsets. These can usually be avoided by adjusting the dose.

Leukotriene receptor agonists do not generally cause side effects, although there have been reports of stomach upsets, feeling thirsty and headache.

Side effects of steroid tablets

Oral steroids carry a risk if they are taken for more than three months or if they are taken frequently (three or four courses of steroids a year). Side effects can include:

• osteoporosis (fragile bones)  
• high blood pressure (hypertension)  
• diabetes
• weight gain  
• cataracts and glaucoma (eye disorders)  
• thinning of the skin  
• easy bruising  
• muscle weakness

To minimise the risk of taking oral steroids:

• Eat a healthy, balanced diet with plenty of calcium. 
• Maintain a healthy body weight. 
• Stop smoking (if you smoke).  
• Do not drink more than the recommended daily amount of alcohol (three to four units a day for men, and two to three units for women). A unit of alcohol is equal to about half a pint of normal strength lager, a glass of wine or a single measure (25ml) of spirits. 
• Do regular exercise.

You will also need regular appointments to check for high blood pressure, diabetes and osteoporosis.

Want to know more?

• Asthma UK: side effects of asthma medicines.

Occupational asthma

If it is possible that you have occupational asthma, you will be referred to a respiratory specialist to confirm the diagnosis. If your employer has an occupational health service, they should also be informed, along with your health and safety officer.

Your employer has a responsibility to protect you from the causes of occupational asthma and it may sometimes be possible to substitute or remove the substance that is triggering your occupational asthma from your workplace. A number of steps can be taken to minimise the impact of occupational triggers. However, you may need to consider changing your job or relocating away from your work environment as soon as possible, ideally within 12 months of your symptoms becoming apparent.

Some people with occupational asthma may be entitled to Industrial Injuries Disablement Benefit.

Want to know more?

• Asthma UK: Occupational asthma.
• Asthma UK: Workplace charter – aimed at employers, employees and health professionals.
• DirectGov: Industrial Injuries Disablement Benefit.

Asthma attacks

Your personal asthma action plan will help you recognise the initial symptoms of an asthma attack and know how to respond and when to seek medical attention.

Treatment of asthma attacks usually involves taking one or more doses of your reliever medicine. If the symptoms of the asthma attack progress and worsen, you may require hospital treatment. If you are admitted to hospital, you will be given a combination of oxygen, reliever and preventer medicines to bring your asthma under control.

Your personal asthma action plan will then need to be reviewed, so that the reasons for your asthma attack can be identified and avoided in future.

Want to know more?

• Asthma UK: What to do in an asthma attack.

Complementary therapies

A number of complementary therapies have been suggested for the treatment of asthma, including:

• breathing exercises 
• traditional Chinese medicine  
• acupuncture  
• ionizers, which are devices that uses an electric current to charge (ionize) molecules of air  
• the Alexander technique, a training programme designed to change the way you move your body  
• homoeopathy
• dietary supplements

There is little evidence that any of these treatments, other than breathing exercises, are effective.

There is good evidence that breathing exercises, including breathing exercises taught by a physiotherapist, yoga and the Buteyko method (a technique involving shallow breathing) can improve symptoms and reduce the need for reliever medicines in some people.

Want to know more?

• Asthma UK: Complementary therapies.