Guideline recommendations for managing acute loss of asthma control in adults using an asthma action plan (AAP)

BTS/SIGN 2016 [8]GINA 2016 [7]CTS 2012 [9]
Criteria for initiating increase in controller medication (“activating the yellow zone”) and duration of changePersonalised action plans should be triggered by symptoms and/or peak flows (PEF between 60 and 80% best suggested for increase in inhaled corticosteroid). Timing and duration of change not specifiedWhen there is a clinically important change from the patient's usual level of asthma control, for example, if asthma symptoms are interfering with normal activities, or PEF has fallen by >20% for more than 2 days. Duration of change 1–2 weeksAction plans should outline when and how to adjust reliever and controller therapy for loss of control. Specific symptoms, or PEF thresholds and timing for increasing controller medication not provided. Duration of change 1–2 weeks
How to adjust ICS monotherapy during acute loss of asthma controlIn adult patients on a very low dose of ICS, a five-fold increase in dose at the time of an asthma attack leads to a decrease in the severity of asthma attacks. Duration of change not specified.
Doubling the dose of ICS at the time of an exacerbation is of unproven value.
At least double ICS; consider increasing ICS to high dose (maximum 2000 µg·day−1 BDP equivalent).Increase the ICS dose by four- or five-fold for 7–14 days in adults with a history of severe exacerbations in the past year requiring systemic steroids.
Level of evidence: Level 1+#Level of evidence: Evidence BLevel of evidence: Grade 2C+
How to adjust ICS/LABA combination medications during acute loss of asthma control (other than ICS/formoterol combination medications)No specific recommendations.Step up to higher dose formulation of ICS/LABA, or consider adding a separate ICS inhaler (to maximum total 2000 µg·day−1 BDP equivalent).Fourfold or greater increase in ICS dose for 7–14 days in individuals who are exacerbation-prone.
Level of evidence: N/ALevel of evidence: Level DLevel of evidence: Consensus+
How to adjust ICS/formoterol combination medications (used as AMD or MART) during acute loss of asthma controlAMD: No specific recommendations pertaining to AAPs.
MART: No specific recommendations pertaining to AAPs.
AMD: quadruple maintenance dose (maximum formoterol 72 µg·day−1).
MART: continue maintenance dose and increase reliever use as needed (maximum formoterol total 72 µg·day−1).
AMD: increase to a maximum of four inhalations twice daily for 7–14 days.
MART: continue use in lieu of increasing the ICS dose of fixed-dose ICS/LABA combination therapy.
Level of evidence: N/ALevel of evidence:
AMD: Level B
MART: Level A
Level of evidence:
AMD: Grade 2B+
MART: Grade 2B+
Instructions for patients who do not respond to first-line therapy (increases in their controller therapy) during acute loss of asthma controlPatients may safely hold an emergency supply of prednisolone tablets for use if their symptoms continue to deteriorate and/or if their peak flow falls to 60% of their best. Recommend prednisolone 40–50 mg daily for at least 5 days or until recovery.Patients who fail to respond to an increase in reliever and controller medication for 2–3 days or deteriorate rapidly should take prednisone 1 mg·kg−1·day−1 (maximum 50 mg) for 5–7 days.No specific recommendations.
Level of evidence: Level 1++#Level of evidence: Level ALevel of evidence: N/A
Alternative action plan instructions for specific patient populations unlikely to benefit from increases in inhaled controller medications alone during acute loss of asthma controlIn patients already taking moderate or high doses (≥400 µg·day−1 BDP equivalent daily) of inhaled corticosteroids, begin oral steroids (prednisolone 40–50 mg daily for at least 5 days or until recovery).In patients who present with PEF or FEV1 <60% of their personal best or predicted value, or have a history of sudden severe exacerbations, start prednisone 1 mg·kg−1·day−1 (maximum 50 mg) for 5–7 days.In individuals over the age of 15 years with a history of severe acute loss of asthma control in the preceding year, start prednisone 30–50 mg daily for at least 5 days.
Level of evidence: N/ALevel of evidence: Level ALevel of evidence: N/A

#: 1++ indicates high quality meta-analyses, systematic reviews or randomised controlled trials (RCTs), or RCTs with a very low risk of bias; 1+ indicates well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias (British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS/SIGN) recommendation ranking system). : Level A: recommendation from RCTs, from a rich body of data, from well-designed studies with a consistent pattern of findings, from a large number of studies with a substantial number of patients. Level B: recommendation from RCTs, with limited body of data, from studies with limited number of patients, from subgroup or post-hoc analyses, or meta-analyses of RCTs or studies with inconsistent results. Level D recommendation from expert opinion, based on clinical experience or knowledge that cannot be included in category C. (Global Initiative for Asthma (GINA) evidence levels.) +: 2B is a weak recommendation with moderate quality of evidence. 2C is a weak recommendation with low quality of evidence. Consensus recommendation implies lack of evidence, where a recommendation is made based on expert opinion and practice experience. (GRADE system). CTS: Canadian Thoracic Society; ICS: inhaled corticosteroid; LABA: long-acting beta-agonist; AMD: adjustable maintenance dosing with ICS/formoterol combination inhalers; MART: maintenance and reliever therapy using an ICS/formoterol combination inhaler; PEF: peak expiratory flow; BDP: beclomethasone diproprionate; FEV1: forced expiratory volume in 1 s; N/A: not available.