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Step 5 options?

I really am hoping I can avoid step 5 when at the chest clinic in a week and a half. However, the reality is that things aren't great right now (maybe not helped by the additional stress of me wanting to get to step 5).

If it does come to it, what are the potential things that they might suggest? Can anyone give me an idea of the options? I know the meds will have a big say but it would be good to have an idea. I'm just looking for some options I can read up on so its not so scary on the day.

I'm currently on the top end of step 4 and not really well controlled at all (although some pred has helped in the last few days).

:) Tina

18 Replies


according to bts guidelines :

step 5 is usually with addition of daily steroids - maintenance dose



Step 1 - Occasional use of inhaled short-acting beta2 agonists: In case of very mild asthma, your doctor is likely to recommend short-acting bronchodilators such as Salbutamol or terbutaline. These medicines are normally used as inhalers to relieve minor symptoms. Beta2 agonists alone are prescribed when its occasional use allows you to lead an active and normal life and you do not suffer from symptoms at night or after exercise. In case you need to use beta2 agonists inhalers more than once a day or three times a week, the treatment regimen will be as for step 2 of asthma management.

Step 2 - Regular use of inhaled steroids: Medicines recommended for this stage of asthma includes inhalation of short-acting beta2 agonists whenever necessary and inhaled steroidal anti-inflammatory medicines. These could be either beclomethasone or budesonide or fluticasone. The normal adult dose is about eight hundred micrograms per day. In case of children, sodium chromoglycate or nedochromil sodium may be used instead of inhaled steroids.

Step 3 - High dose of inhaled steroids: Medicines recommended in this stage of asthma severity include inhaled short acting beta2 agonists as required plus an inhaled steroid in a higher dose. The dose of inhaled steroid is normally in the range of eight hundred to two thousand micrograms per day for an adult. In case you need to inhale large doses of steroids through a metered dose inhaler, it is desirable that you use a large volume spacer, which has a hold chamber. In case you use dry powder inhalers, it is desirable that you rinse your mouth after every inhaler treatment in order to avoid candidiasis in the mouth or throat.

Step 4 - High dose of inhaled steroids and regular use of bronchodilators: Treatment of severe asthma involves inhalation of short-acting beta2 agonists as required, plus a high dose of inhaled steroids, plus regular use of bronchodilators.

Since there are several types of bronchodilators, and each of them act differently, your doctor is likely to try and manage your asthma with one or more of the following medicines:

Inhaled long-acting beta2 agonists such as salmeterol or formoterol. Sustained release theophylline. Inhaled ipratropium bromide or oxitropium bromide

Long-acting oral beta2 agonist such as sustained release salbutamol or terbutaline preparations

High dose of inhaled bronchodilators. Sodium chromoglycate or nedochromil sodium

Step 5 - Addition of oral steroids: Treatment of very severe asthma includes (a) inhaled short-acting beta2 agonists as required, (b) inhaled steroid in a high dose of about eight hundred to two thousand micrograms per day, (c) one or more of the long acting bronchodilators and (d) oral steroids such as prednisolone. The dose of oral steroids is maintained at the minimum that is able to control asthmatic symptoms.


Thanks for the replies :)

I'm really hoping to avoid step 5. That said I guess its just a label. Last time I saw the consultant he

seemed keen on immuno suppressant (sp?) injections. I don't want those. I don't like pred as my stomach doesn't like them. Am on x2 bd seretide 250 accuhaler, is this the top of the scale or might he up it?

Are there any other options anyone knows of?


Afraid I can't help, but I'm watching this thread carefully to see if anyone comes up with something. I'm step 5 + Omalizumab and I feel my consultant's given up on me. :'(


TS in the past I have been on four puffs of seretide 250 inhaler twice a day so there is still room for uping up the dose.


Hello again TS,

Let us know how you get on. Have also been at top step 4. Think the only thing that hasn't been tried is theophylline or similar, not sure when/why that would be done. Now on x1 bd seretide 250 accuhaler but have also been on x2 bd seretide 250 accuhaler which is maximum licensed dose & can go higher. I take it you have seen the guidelines then to know the step you're on. Have had several courses pred already this year and have just been given some to keep if needed.

G.P. is convinced if sinusitis can be controlled, lungs will behave. Doesn't seem keen to refer for asthma, if sinuses not improved more in a fortnight-on 6wk course of 4th antibs- they will then to ENT.

How did you find getting referred to see consultant first? I haven't got very severe asthma, not been to A&E or admitted. Suspect referral could happen then for me or if need more pred. You said your stomach doesn't like it, have you had the enteric coated aka red smarties? It's often prescribed as the standard white tablets now.

Ratty, also interested in seeing what people come up with.


theophylline is normally before step 5...

ratty am also gonna be trying omalivimub... other than that, no ideas what else either :(



TJ, Yes I've seen the guidelines. Last time I was at chest clinic he was thinking about xolair, am not keen on that and am hoping that my control isn't bad enough for it. I too, am not anywhere near as bad as some here. I think my asthma is just being difficult. I've managed to get away without A&E visits as I usually know when its kicking off so can get pred before it gets too bad.

I don't like the smarties! This time, they tried to give me the white ones. Seems there is no difference between them and the coated ones, other than the white ones are more effective. I managed to get the coated ones, the white ones and my stomach really don't get on.

I was refered early on, compared with some on here. If you need the referal, it might be worth asking about it as there always seems to be a long wait time (weeks, sometimes longer). I'll let you know what happens at chest clinic, its in a week or so.


seretide dose


I've been on 6 puffs daily of Seretide 250 for most of the winter. I just went down to 4 a couple of weeks ago with the instruction that if my peakflow dropped 20% to go back on 6 puffs immediately. I didn't realise it isn't licenced for that dose. This instruction is from the consultant. I've never neen in costa or even A+E so wonder why I should need this dose! Just been put on Montelukast which really helps.


I don't really get which step I am at and when but I assume you are looking at what they might suggest as last resort ideas!

When I was told they were running out of options I discovered there are actually a lot of last resort treatments!!

I am currently on Fostair, Siriva, Flixotide, Pred, Nebs and Theophylline.

Have also tried Omalizumab, Methotrexate, SubCutaneous Bricanyl, Hydrocortisone and prophylactic antibiotics. Quite a few options I thought considering they were supposed to be running out.

Best of luck to you


If you are on just seretide 250mcg 4 puffs daily there are still lots of options left,

I am on that plus phyllocontin 225mg 2x daily

Montelukast 10mg daily

Tiotropium 10mcg daily

Regular nebs if required and pred as required plus my inhaler. It might be worth reviewing your triggers as well.

As you can see there are other options as well.



After seeing my consultant he put me on Kenalog injections 40mg once every week (this about 3 years ago) as it contains a slow release of steroids-lower dose than having to take steroids every day and an anti-anflammatory....as far as i know this treatment is well known but it really gave me my life back...deffo worth asking about it tho :)

hop u get on ok Becca


theophylline is what i'm on with steriods as and when needed, am pregnant at the moment and have had to remove them from my meds so been on steriods quite alot but the theophylline work for me.


I'm step 5. Oral theophyllines, montelukast, and omalizumab have all been tried but are no good for me. I saw my consultant today and he wants me to start taking Azithromycin.



Thanks for your replies. Its good to see there are a few options! I'll let you all know how it goes.

:) Tina


Hi,Just wish i could get off step 5 but my lungs wont budge at all even the pred not helping me alot and seem to be on it 24/7 .Nellie has a lot to answer for !x


Hi Glynis.... maybe we can meet in the middle. You step down a touch and I don't go up there. We can have a coffee in the middle somewhere!

My PF isn't too bad after a short course of pred but the chests not feeling that great. Am wondering if its tree pollen, although that doesn't usually affect me in the same way as grass. Still, its not bad for me.

I hope nellie gets off you soon.


Hi TS,

hope Nellie shifts soon.

my pf 250 and 300 at the mo and yo yoing.

Just resting up now after a family weekend as mothers day.

Break up from work for 2 weeks friday so hope rest up lots.

Had a problem today ,had to ring insurance up for son as broke his pc

and covered on insurance,

She said will do it over the phone and takes 40 mins so needed book a time slot.

Told her asthma to bad to talk that long so ringing me Thursday if up to it .

I always smile when mention Nellie as thats my nanas name who died 3 yrs ago age 98 1/2.

I had her name put in mine by deed pole as she was the last of the Ellis ""s (Nellie Ellis) so glad now didnt go for her first name Nellie xxx


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