Ten tips for optimising asthma management at review

Respiratory lead pharmacist Nazir Hussain offers his top practical tips on how to conduct effective asthma reviews and optimise asthma medication in line with updated asthma guidelines

The joint asthma guidelines from NICE, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) represent a significant opportunity to rethink and improve asthma management across the UK.¹

They mark a paradigm shift away from reactive treatment and toward proactive, preventative care. With new strategies such as AIR (Anti-Inflammatory Reliever) therapy, also known as ‘reliever therapy’, and renewed emphasis on MART (Maintenance and Reliever Therapy), there is now greater focus on reducing reliance on SABAs (short-acting beta-agonists) and enhancing long-term control.

With asthma outcomes in the UK the worst in Europe and deprived populations hit the hardest,² pharmacists are uniquely placed to drive change and improve outcomes in these communities.

By optimising asthma medication reviews in line with the NICE/BTS/SIGN guidelines, as pharmacists we can contribute to better control and fewer hospital admissions, and ultimately improve lives.

Here are my real-world practical pointers for practice pharmacists to consider when supporting patients with asthma.

1. Eliminate SABA-only prescribing

Although it has been known for over a decade that SABA monotherapy is linked to increased asthma exacerbations and even death, the practice persists.³ The guidelines now clearly state that no patient with asthma should be managed with a SABA alone.

Action:

• Conduct searches to identify patients with asthma on SABA-only prescriptions.
• Flag these patients for review and initiate preventative treatment where appropriate.
• Consider AIR or MART pathways as first-line options if appropriate.

2. Know when to use AIR

AIR therapy involves using a combination inhaler including an inhaled corticosteroid (ICS) plus formoterol as both the reliever and controller medication, with no separate maintenance therapy. Formoterol is a long-acting beta-2 agonist (LABA) with a rapid onset of action (acts within 1–3 minutes, making it suitable for relieving acute symptoms, just like a SABA). For this reason, patients on an AIR inhaler should not be prescribed a separate SABA inhaler.

Who is AIR for?

In adults and children aged 12 and older AIR should be offered to:

• All patients with a new diagnosis of asthma and symptoms that occur three or less times a week.
• Patients with an existing asthma diagnosis who are on SABA monotherapy and use their reliever inhaler only occasionally.

Who is AIR not suitable for?

• Patients requiring AIR therapy three or more times a week or waking up at night should be changed to MART (see below).
• Patients with severe asthma.

Note also that not all combination ICS-formoterol inhalers are licensed for AIR therapy.

3. Know when to use MART

MART simplifies therapy by using a single inhaler as both preventer and reliever. It offers better symptom control and reduces hospitalisations and deaths in patients with poorly controlled asthma, compared with treatments that involve a separate SABA inhaler.⁴

For patients who pay prescription fees, MART can be more cost effective as it involves only one prescription charge.

Additionally, it supports environmentally sustainable practice by decreasing over-reliance on SABAs.

Who is MART for?

• Adults and children aged 12 and older:
  Patients with an existing asthma diagnosis who remain poorly controlled despite regular ICS plus SABA use should be switched to MART.
• Children aged 5–11 years (off-label use):
  MART may be considered in this group, but currently only with certain dry powder inhalers (DPIs) and on a case-by-case basis.
• Newly diagnosed adults (new recommendation):
  Patients who are highly symptomatic (for example, have regular night-time waking or symptoms of a severe exacerbation) may be started on MART even if they have not yet been on any inhaled therapy. This is a significant change from earlier recommendations, which typically delayed this step until much further down the line.

Who is MART not suitable for?

• Patients with poor understanding of their regimen or asthma condition.
• Patients with poor perception of their symptoms (who may not recognise worsening asthma).

Action:

• Ensure proper training and assessment of inhaler technique before initiating AIR or MART.⁵
• Changes should always be made through a face-to-face consultation.
• Provide an AIR or MART-specific asthma action plan, clearly explaining how the inhaler is to be used both regularly and as needed.
• Follow up to assess response to treatment in approximately four weeks.

For more information on the new asthma guidelines and which patients to prescribe AIR or MART, refer to this useful Primary Care Respiratory Society (PCRS) guide.⁶

4. Address emotional attachment to SABAs

Many patients are reluctant to part with their ‘blue inhaler’, often associating it with control and immediate relief.

Action:

• Use motivational interviewing techniques to engage and empower patients.
• Build rapport and empathy – acknowledge their experience without blame.
• Explore ambivalence and correct misconceptions.
• Educate on how over-reliance on SABAs may mask worsening asthma control and increase risk. Highlight the rebound effects of daily SABA use, such as building airway hypersensitivity to it.
• The way we present information influences patient behaviour. Use airway models or clear online illustrations to explain bronchoconstriction and inflammation. Ensure patients understand that the blue reliever inhaler relaxes airway muscles for quick relief, but doesn’t treat underlying inflammation – unlike the single AIR or MART inhaler. Share anecdotes to make the information relatable.

5. Check inhaler technique every time

Incorrect inhaler technique is a key contributor to poor asthma control, increased side effects, over-reliance on reliever inhalers and higher prescribing costs. It is essential to match inhaler types and regimens to each patient’s individual needs, dexterity and lifestyle. For example, a DPI may not be suitable for someone who needs to use their inhaler during water sports. For more information on how to tailor inhaler devices to patients, refer to this handy PCRS guide.⁷

Action:

• Assess technique at every review, even for long-term users.
• Aim for consistency in device types – avoid mixing DPI and MDI unless necessary.
• All patients using an MDI, including adults, should be issued a spacer device as it improves drug delivery and reduces oropharyngeal side effects.
• Remind patients that spacers should be replaced annually or sooner if worn or broken.

6. Support shared decision-making

The most effective inhaler is one the patient can use confidently and is willing to use regularly.

Action:

• Engage patients in treatment decisions.
• Explore and address their preferences and barriers to adherence.

7. Promote use of Personal Asthma Action Plans (PAAPs)

PAAPs are critical tools for self-management. They outline medication use, symptom monitoring, triggers, and what to do during exacerbations.

Action:

• Create or update a PAAP during each review. Include advice on managing known triggers (eg, starting hay fever treatment before pollen season).
• Use accessible formats – translated versions, pictograms, or electronic copies where needed.
• Emphasise that PAAPs are not just for emergencies – they support everyday asthma management.
• Ask at each review: ‘Would you recognise and know what to do if you had an asthma attack?’

8. Know when to escalate

Asthma control should be measured using a validated assessment test – eg, the Asthma Control Test or Reliever Reliance Test.⁸ If asthma remains uncontrolled despite good adherence and technique, reassessment is essential.

Action:

• Question the diagnosis: Is this truly asthma, or could another condition be contributing?
• Identify multimorbidity (eg, rhinitis, reflux, obesity, anxiety) that may impact control.
• Consider referral for specialist review, particularly if the patient may be eligible for biologics or further tests.

Timely referral can significantly improve patient outcomes and quality of life. The International Primary Care Respiratory Group (IPCRG) has a useful to guide on how to manage difficult asthma cases including when to refer.⁹

9. Prioritise person-centred care

Asthma management must be tailored to the individual. Differences in phenotype, cultural and health beliefs, and social circumstances all influence treatment success. If you only have 20 minutes with a patient, avoid trying to cover everything at once. Focus on the most pressing issues first and schedule a prompt follow-up to address the remaining urgent concerns as soon as practical.

Action:

• Provide extra support to vulnerable groups – this may include longer appointments, interpreter services, PAAPs in the patient’s own language or more frequent follow-ups.
• Look out for poor health literacy and learning difficulties and make reasonable adjustments.
• Use every review to build trust and increase the patient’s understanding of their condition and treatment.

10. Be consistent – and don’t forget QOF

Asthma is a chronic condition that requires ongoing attention – not just a once-a-year check-up. Pharmacists are in a strong position to provide continuity of care, reinforce guideline-based treatment and support patients in achieving better control.

It is important as part of this to ensure that the asthma QOF templates are completed accurately and correctly coded. The last thing you want is to recall patients unnecessarily for reviews they don’t need, wasting both patient and practice time and valuable resources.

By delivering thorough, person-centred asthma medication reviews, pharmacists can help reduce preventable admissions, improve lives, and close the gap in health inequalities.

Let’s make every review count.

Nazir Hussain is Respiratory Workstream Lead Pharmacist at Black Country ICB, Specialist Respiratory Pharmacist at Dudley Group NHS Foundation Trust, Executive Committee Member of PCRS and RPS Expert Advisor (Primary Care)