BTS/NICE/SIGN 2024 asthma guideline (NG245): diagnosis and management

Who it applies to

Applies to children, young people and adults with suspected or confirmed asthma in primary and secondary care settings in the UK.

Key recommendations

• Diagnosis should be based on objective tests rather than symptoms alone, using a combination of spirometry, FeNO testing and peak flow or bronchodilator reversibility testing depending on age and availability.
• FeNO testing is recommended as part of the initial diagnostic workup to support identification of eosinophilic airway inflammation.
• A structured diagnostic algorithm is used that varies by age group, with different combinations of tests recommended for adults versus children.
• Low-dose inhaled corticosteroid (ICS) therapy, often as part of a combination ICS/long-acting beta agonist used for both maintenance and reliever therapy (MART), is favoured as an early treatment approach rather than short-acting beta agonist only reliever use.
• Short-acting beta agonist reliever inhalers used alone without concurrent ICS are discouraged because of safety concerns around overreliance.
• Treatment is organised as a stepwise pathway, escalating ICS dose or adding additional controller therapy based on symptom control and exacerbation history, with regular review before stepping up.
• Step-down of treatment should be considered once asthma has been well controlled for a sustained period, reducing to the lowest effective dose.
• Inhaler technique and device choice should be assessed and optimised at every review, alongside checking adherence before escalating therapy.
• Personalised asthma action plans should be provided to all patients to support self-management and recognition of worsening control.
• Specialist referral should be considered for those with poor control despite optimised treatment, to assess for difficult-to-treat or severe asthma including biologic therapy eligibility.

What is new in this edition

• Unification of the previously separate NICE and BTS/SIGN asthma guidelines into a single joint guideline (NG245).
• Greater emphasis on combination ICS-containing reliever therapy (MART-type approaches) over traditional short-acting beta agonist reliever-only strategies.
• Clarified, age-stratified objective diagnostic pathway incorporating FeNO more explicitly.

Practice points for students

• Avoid diagnosing or treating asthma based on symptoms alone; objective confirmation is central to this guideline.
• Short-acting beta agonist monotherapy without ICS is now actively discouraged, a key shift testable in exams.
• Always check inhaler technique and adherence before labelling someone as needing a treatment step-up.
• Remember that diagnostic test combinations differ between children and adults, a common source of exam confusion.
• Provide a written asthma action plan as a routine part of management, not just for severe disease.

Condition

Other guidelines on this topic

• A New Approach to Reliever Therapy in Asthma: Implications of the U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice GuidelineACP2026Official guideline
• Allergic Rhinitis and Its Impact on Asthma (ARIA)-EAACI Guidelines-2024-2025 Revision: Part I-Guidelines on Intranasal TreatmentsEAACI2026Full text
• Biologic Management in Severe Asthma for Adults: An American College of Chest Physicians Clinical Practice GuidelineCHEST2026Official guideline
• European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5-16 yearsERS2021Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.