The national guideline moved to SABA-free treatment. Here is the switching table, the inhaler doses, what to do in an attack — and the beliefs about steroids and nebulisers you will have to work through first.
| Mild | Minimal symptoms and minimal risk of exacerbations in patients not using inhaled therapies, using reliever therapy alone, or using low-dose inhaled glucocorticoids with reliever therapy. |
| Moderate | Good asthma control on medium-dose inhaled glucocorticoids, or low-to-medium dose inhaled glucocorticoids with additional controller therapy. |
| Severe | Asthma requiring high-dose inhaled glucocorticoids with additional controller agents to maintain good control, or asthma that stays uncontrolled despite those therapies. |
By these definitions severity can only be assessed after achieving good control and stepping down to the minimum effective controller therapy — or where asthma stays uncontrolled despite maximised treatment. Assess it after several months of controller treatment, when the asthma is stable, not at the first consultation.
The guideline asks that any of these be documented in the clinical notes and the patient told to seek urgent help if an exacerbation starts.
For a patient presenting for the first time who is on no asthma medicine, the choice of initial drug depends on the severity of symptoms — and SABA-free pathways, meaning AIR or MART, are recommended to reduce the risks of SABA overuse.
Identify adults and children 12 and over who can be switched, particularly where asthma is not controlled. Start a conversation about switching, especially if they remain symptomatic.
| Current treatment | Switch to |
|---|---|
| SABA only | Low-dose ICS-formoterol as needed (AIR) |
| Regular low-dose ICS + SABA as needed | Low-dose MART |
| Regular low-dose ICS-LABA + SABA as needed | Low-dose MART |
| Regular low-dose ICS + LTRA and/or LAMA + SABA as needed | Low-dose MART |
| Regular low-dose ICS-LABA + LTRA and/or LAMA + SABA as needed | Low-dose MART |
| Regular moderate-dose ICS + SABA as needed | Moderate-dose MART |
| Regular moderate-dose ICS-LABA + SABA as needed | Moderate-dose MART |
| Regular moderate-dose ICS + LTRA and/or LAMA + SABA as needed | Moderate-dose MART |
| Regular moderate-dose ICS-LABA + LTRA and/or LAMA + SABA as needed | Moderate-dose MART |
| Any high-dose ICS-containing regimen | Refer to specialist asthma care |
Adapted by the guideline from the joint BTS/NICE/SIGN guideline NG245.
Total daily ICS dose in micrograms. Adapted by the guideline from GINA 2025.
| Inhaled corticosteroid | Low | Medium | High |
|---|---|---|---|
| Beclometasone dipropionate (pMDI, standard particle, HFA) | 200–500 | >500–1000 | >1000 |
| Beclometasone dipropionate (pMDI or DPI, extra-fine particle, HFA) | 100–200 | >200–400 | >400 |
| Budesonide (pMDI or DPI, standard particle, HFA) | 200–400 | >400–800 | >800 |
| Ciclesonide (pMDI, extra-fine particle, HFA) | 80–160 | >160–320 | >320 |
| Fluticasone furoate (DPI) | 100 | — | 200 |
| Fluticasone propionate (DPI) | 100–250 | >250–500 | >500 |
| Fluticasone propionate (pMDI, standard particle, HFA) | 100–250 | >250–500 | >500 |
| Mometasone furoate (DPI) | Depends on the DPI device | ||
| Mometasone furoate (pMDI, standard particle, HFA) | 200–400 | >400 |
The guideline prefers the term "flare-up" in clinical settings, because patients and caregivers understand it.
| Mild or moderate | Severe | Life-threatening | |
|---|---|---|---|
| Speech | Talks in phrases | Talks in words | Drowsy, confused |
| Posture | Prefers sitting to lying | Sits hunched forward | |
| Agitation | Not agitated | Agitated | |
| Respiratory rate | Increased | Above 30/min | |
| Accessory muscles | Not using them | Using them | |
| Pulse | 100–120/min | Above 120/min | |
| SpO₂ | 90–95% | Below 90% | |
| PEF | Above 50% predicted or best | 50% predicted or best or less | Quiet chest |
Every patient and caregiver should have a written asthma action plan, and be taught to use it. It should be built around the reliever they actually have: ICS-formoterol, ICS-SABA, or SABA. On a MART pathway, one inhalation of ICS-formoterol whenever needed, to a maximum of 12 inhalations in 24 hours including maintenance doses. On an ICS-SABA pathway, two inhalations whenever needed, to a maximum of 6 doses — 12 inhalations — in 24 hours.
The guideline devotes a table to this, because myths about asthma "lead to confusion, stigma, and sometimes even harmful decisions about treatment". Most of these will be familiar from any Pakistani outpatient clinic.
| What you will hear | What to say |
|---|---|
| Inhaled steroids are addictive | Inhaled steroids are safe and not habit forming. |
| Inhaled steroids are harmful | Inhalers deliver a very small amount of steroid to have any harmful effect. |
| Asthma can be managed with a salbutamol inhaler alone | Asthma is a disease of inflammation rather than bronchoconstriction alone. A salbutamol inhaler does not treat inflammation. |
| Asthma medicines are only used when having symptoms | They should be taken even when asymptomatic, because they control the disease and prevent exacerbations. |
| Nebulisers are better than inhalers | Inhalers are easier to use and as efficient as nebulisers. Many controller medicines cannot be given by nebuliser at all. |
| Spacers are only for children | Spacers matter at every age — they get the medicine to the lungs instead of depositing it in the mouth and throat. |
| People with mild asthma cannot die of it | Any severity of asthma can have an exacerbation, and it may be mild or severe. |
| People with asthma have weak lungs | Lungs in asthma are not weak. They react too strongly to allergens. |
| Asthma is curable | Asthma is not curable, but it is treatable. |
| People with asthma should not exercise, or play sport | Exercise is good for lung health, and controlled asthma carries no restriction on playing. Where exercise-induced asthma exists, an inhaler can be prescribed to use beforehand. |
| No wheeze means no asthma | Symptoms differ between people. Not all wheeze is asthma, and no wheeze does not mean no asthma. |
| Only poor outdoor air quality triggers asthma | Indoor air quality matters as much as outdoor in preventing asthma worsening. |
| Vaccination triggers asthma | Vaccines do not trigger asthma; they prevent infections that commonly trigger exacerbations. |
| Allergies are not related to asthma | Most people with asthma have allergies, which may trigger cough, breathlessness and wheeze. |
A national society labelling its own central recommendation an extrapolation is unusual, and it is the honest position. It does not make MART the wrong choice — the regional evidence behind it is real, and it is summarised below. It does mean the confidence attached to it here should be a notch lower than the confidence attached to it in London, and that Pakistani trial data is a gap worth someone filling.
| Study | Setting and design | Population | Key outcome |
|---|---|---|---|
| SMARTASIA (2013) | Multi-country Asia — China, India, Thailand, Taiwan, Indonesia — Real-world phase IV | Adults with partially controlled asthma | Budesonide-formoterol as maintenance and reliever in one inhaler improved ACQ-5 and AQLQ-S significantly versus budesonide-formoterol twice daily plus separate salbutamol. |
| COSMOS Asian sub-analysis | Asia RCT subgroup — China, Korea, Taiwan, Thailand — Open-label RCT | 16 years and over, moderate asthma | 38% fewer exacerbations with adjustable budesonide-formoterol dosing versus fixed-dose fluticasone-salmeterol plus salbutamol as needed. |
| Paediatric China (2020–21) | Real-world cohort and model — Retrospective plus modelling | Children under 18 | MART had lower exacerbation rates than a traditional ICS-maintenance-plus-salbutamol regimen, and was cost-effective. |
Three or more 200-dose canisters a year increases the risk of exacerbation, and one canister a month or more increases mortality. In a country where salbutamol is cheap and sold over the counter, ask how many canisters the patient goes through rather than whether they use one.
Low-dose ICS-formoterol as needed — the anti-inflammatory reliever, or AIR, pathway. A patient on regular low-dose ICS with a SABA reliever switches to low-dose MART; a patient on moderate-dose ICS switches to moderate-dose MART; anyone on a high-dose ICS-containing regimen should be referred to specialist asthma care.
No. The guideline says to identify adults and children 12 and over who can be switched, particularly where asthma is not controlled — but if they are asymptomatic and happy on their current pathway, it is not recommended that they be transferred.
No. ICS-formoterol must never be used as the reliever alongside a maintenance ICS-LABA that is not formoterol. And ICS with a non-formoterol LABA, or ICS-SABA, cannot be used as MART at all.
Adults 40–50 mg/day for 5–7 days. Children 0.5 mg/kg/day, maximum 40 mg/day, for 3–5 days. Tapering is not needed if the course is under two weeks.
In the emergency department for a severe exacerbation — 2 g intravenously over 20 minutes, alongside SABA, ipratropium bromide, systemic corticosteroids and oxygen. A life-threatening exacerbation goes to ICU.
93–95% in adults, and 94% or above in children.
No to both, and the guideline lists these among the myths it wants clinicians to correct. Inhaled steroids are not habit forming, and inhalers deliver a very small amount of steroid. The related myth that matters most is that asthma can be managed with a salbutamol inhaler alone — asthma is a disease of inflammation, and salbutamol does not treat inflammation.
The guideline says so itself: there is a notable absence of robust clinical data from Pakistan, and the strategy it recommends is an extrapolation from studies in western and other Asian countries. The regional evidence — SMARTASIA, the COSMOS Asian sub-analysis and a Chinese paediatric cohort — is real, but Pakistani trial data is a genuine gap.
Also in this section: community-acquired pneumonia and tuberculosis — the two respiratory differentials that matter most here — plus pre-eclampsia, hypertension, type 2 diabetes, hepatitis C and urinary tract infection. See all clinical pathways and clinical tools.