Asthma in children: Is the future AIR not SABA?

One of the big areas we are covering in the current Hot Topics course is asthma. Why? Well, to put it bluntly, asthma outcomes in the UK are terrible - as discussed in the BJGP in 2024 we have higher rates of preventable attacks, healthcare costs and deaths from asthma compared with the majority of other European countries. There are a multitude of reasons for this, but the long awaited joint asthma guideline from BTS/SIGN/NICE (published a year to the day this blog goes out) brings clarity and simplicity to how we should diagnose and manage asthma, and should improve asthma outcomes. 

Risks of SABA monotherapy

One of the key messages from the guideline is that the use of short acting beta agonist (SABA) inhalers on their own is bad news and is a key driver for our poor asthma outcomes. Combination inhalers with both inhaled corticosteroid (ICS) and formoterol should be used instead for older children (aged over 12) and adults, both in PRN/as needed (anti-inflammatory reliever = AIR) regimes and for regular (maintenance and reliever therapy = MART) regimes.

What about younger children?

Yet one of the uncertainties in the new guideline is how we manage children aged 5-11 years old with milder symptoms. For this age group the guideline recommends that at step 1 ALL children with asthma should initially be prescribed a regular twice daily ICS inhaler alongside a SABA for PRN use, but it could not recommend AIR therapy at step 1 (I.e. combo ICS/formoterol inhaler for PRN use) given the lack of evidence for this regime in younger children. But as discussed in a hard hitting editorial in the BJGP last year ‘Asthma deaths in children in the UK: the last straw!’  this is a group that desperately needs improved care. The article highlights that we’ve known for more than three decades that insufficient ICS use and overuse of SABA in children is associated with asthma attacks and death, that previous recommendations from the national review of asthma deaths (NRAD) 10 years ago have not been acted on, and that ‘asthma is just not taken seriously enough in the UK’. 

As discussed in a recent Lancet editorial, knowing how to best manage children with mild/moderate asthma is crucial given the NRAD report showed that over half of asthma deaths in children were in those with mild/moderate asthma, who are more likely to be using PRN regimes, often with SABA and not enough ICS. Could the AIR regime be helpful in reducing asthma attacks in children, as has been shown in adolescents and adults?

Giving some AIR to CARE

This question has recently been addressed in an important RCT based in New Zealand (Lancet October 2025). The CARE trial is the first RCT comparing ICS-formoterol (AIR/MART) vs SABA +/-ICS therapy in children. It randomised 360 children aged 5-15 years old with mild/moderate asthma with episodic symptoms to either an AIR regime (PRN budesonide/formoterol combination inhaler) or SABA as needed. If children had an asthma attack their care was stepped up to a MART regime (for the AIR group) or to regular ICS with fluticasone plus PRN SABA (in the SABA group). The primary outcome was the number of asthma attacks in the 12 month follow up period, defined as acute asthma symptoms requiring urgent unplanned care either without the need for oral steroids (moderate attack) or with the need for oral steroids (severe attack).

The results strongly favour use of the newer AIR/MART regime over the standard SABA/ICS regime. The absolute rate of asthma attacks/year per child was 0.23 vs 0.41, giving a relative reduction of 45% (RR 0.55, 95% CI = 0.35-0.86). Some key secondary outcomes also favoured the AIR group, including reduced mean oral steroid requirements, a reduction in the number of children having ≥1 asthma attacks (17% vs 32%, OR 0.43, 95% CI = 0.24-0.75), and a reduction in the rate of severe asthma attacks (RR 0.60, 95% CI = 0.32-1.14); the severe asthma attack rate was not statistically significant predominantly due to the fact that the trial was hit by the COVID pandemic and lockdowns, which resulted in a substantial drop in overall severe asthma attacks thus weakening the sample size. Importantly there were no significant differences between the two groups in adverse effects including growth velocity. 

A few caveats and other points worth noting include the observation that overall FeNO levels and symptom scores were similar in both groups, showing that the main benefit of AIR is the reduction in asthma attacks, not overall symptom burden. The other important observation was that subgroup analysis suggests that the treatment effect was less pronounced in the 5-11 year old age group (~70% of the trial participants) vs older children aged 12-15 years (~30% of the trial participants), although in that younger group there was still a ~30% reduction in asthma attacks.

What does this mean for us now in General Practice? 

This trial certainly supports the new BTS/SIGN/NICE guideline to use AIR/MART in children aged over 12 years old. As for children aged 5-11 years, especially those at the younger end of that spectrum a degree of uncertainty remains. As discussed in the associated editorial further data is likely to be needed in that younger cohort before guidelines can be definitively changed. However, this trial supports the notion that for children at the older end of the 5-11 years spectrum, considering an AIR regime initially at step 1 is a reasonable option, and it certainly supports the current guidance that if step up treatment is needed a MART regime is preferable over the traditional approach, if the child is able to manage the MART regime. 

And for a full update on the new asthma guidelines, our current Hot Topics update course is available now on demand or live and interactive on January 23rd!