Practice dilemma: How can I step up a child’s asthma treatment when licensed MART is not an option?

Respiratory consultant nurse and children’s asthma clinical fellow Aleksandra Gawlik-Lipinski explains how to manage this tricky case of a child with poor asthma control who requires a step-up in treatment, but isn’t able to use a dry powder inhaler (DPI) licensed for Maintenance and Reliever Therapy (MART).

The dilemma: You are reviewing a 9-year-old girl who was diagnosed with asthma 2 years ago. She is currently on a low-dose inhaled corticosteroid (ICS) and short-acting beta2-agonist (SABA) but, despite trigger avoidance, good adherence and inhaler technique, her symptoms are not well controlled. Her Child’s Asthma Control Test (ACT) score during the appointment today was 17/27. You assess her as suitable for MART, but find she is unable to use a DPI. What are the next steps?

Asthma affects around 1 in 11 children in the UK (Transformation Partners in Healthcare 2023) and it is common for these patients to experience difficulty controlling their asthma.¹

In this case the patient’s asthma control is poor, below 20 on the Children’s ACT, despite reported good inhaler technique and adherence.

In line with asthma guidelines, she should be offered step-up treatment to MART if suitable (BTS/NICE/SIGN 2024).² This pathway anticipates the use of a single combined inhaler, containing an inhaled corticosteroid (ICS) and formoterol (long-acting beta2-agonist; LABA), meaning that the patient takes their regular preventer dose daily and additional puffs as required to manage symptoms.

MART is known to provide better symptom control, reduce exacerbations and hospitalisations.³ However, the choice of inhalers in this age group is limited, with only one DPI currently licensed (Symbicort 100/6) for use in children over the age of 6, and no licensed pressurised meter dose inhalers (pMDIs).

Related Article: Case by case – diagnosing asthma in adults

How should MART be initiated?

Firstly, the nurse must be competent to initiate MART in this age group. Healthcare professionals (HCPs) who recommend, prescribe or manage/monitor the MART regime in children and young people should have at least Tier 3-level children’s asthma training as stipulated in The National Capabilities Framework.⁴

Next, it should be checked whether the patient can use MART – does the child have sufficient inspiratory flow to use a DPI (only licensed option) and an understanding of the regimen?

Many children in this age group will be capable of using a DPI. However, it is crucial to always assess the individual patient’s capability to grasp the different technique required.

In addition, while a 9-year-old child should, in principle, be capable of understanding how and when to use their inhaler, their parent/carer must also have a full understanding of the MART regimen to adequately support the child with medication intake.

In an ideal world, DPI could be prescribed now, a personalised asthma action plan (PAAP) created, and frequent reviews scheduled.

In this case, however, the patient is unable to use the DPI – most likely due to an inability to take a quick, strong breath in.

Can you prescribe an off-label pMDI MART option instead?

Following the BTS/NICE/SIGN guidance, an off-label prescription of pMDI – Symbicort 100/3 – should be considered. Yet the dose of formoterol in Symbicort 100/3 is half of that contained in the DPI, putting the patient at risk of high steroid intake if additional doses are taken. Furthermore, there is no current evidence on the safety of using this product for MART therapy in this age group.⁵

Therefore, this particular off-label pMDI is not considered a routine treatment option in general practice and should only be initiated by adequately trained (Tier 4 or above) clinicans (including nurses),⁶ typically found in specialist asthma clinics.

Moreover, any child initiated on Symbicort 100/3 should be reviewed initially on a 3-monthly basis, with close monitoring of treatment efficacy and steroid dose. The PAAP must stress the need to contact their clinic nurse in case of regular use of additional puffs, and regular use of >800mcg ICS per day should grant a referral to a secondary or tertiary centre.⁶

Having taken the above into consideration, if the patient is unable to use DPI and the clinician is not trained at least to the Tier 4 level, Symbicort 100/3 for MART should not be prescribed.

In such a case, in line with the BTS/NICE/SIGN asthma guidance the step-up includes consideration of a trial of a leukotriene receptor antagonist (LTRA) such as montelukast.²

If the LTRA is ineffective over 8-12 weeks, or results in side effects, it should be discontinued. The next step is then to prescribe a low-dose ICS/LABA combination pMDI inhaler with a spacer and a separate SABA inhaler (refer to your local formulary). Multiple inhalers are licensed for that purpose.⁶ The child should be reassessed for MART suitability at a later time.

Other considerations, if prescribing off label

Should the clinician have an adequate level of training and agree with the patient, parent or carer that they are a suitable candidate for the pMDI Symbicort 100/3, they must be aware of the legal framework around prescribing off-label medication.

Prescribing off-label carries additional responsibilities for the prescriber. As a prescriber, you become the judge of whether the off-label medication will be prescribed in the best interest of the patient based on the evidence available at the time. Legally, nurse independent prescribers are allowed to prescribe off-label if the product meets the above criterion, they are satisfied that there is no alternative and that the evidence available is sufficient to support prescribing, is prescribed within their clinical competence, and they adhere to the NMC code and to their workplace prescribing policies.⁷

The reasons for prescribing off-label products must be documented in the patient’s record, and the patient (or parent/carer) must be informed about the indication for the treatment, treatment information (including regimen, side effects and how to act on them) and the licensing status.⁷

Make sure the basics are in place

Finally, we must always ensure that the basics of care are delivered – by creating an individualised PAAP, checking and/or training in inhaler technique, including with the use of a spacer for pMDIs, and booking follow-up after the initiation of the new medication.

Aleksandra Gawlik-Lipinski is respiratory consultant nurse at South Leicestershire Medical Group, PhD Candidate at the University of Leicester, and a clinical fellow for the Children and Young People Asthma Workstream at the Royal College of Physicians National Respiratory Audit Programme

References

Transformation Partners In Healthcare. Children and young people’s asthma fact sheet. 2023
NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] November 2024
Beasley R et al. Evaluation of Budesonide-Formoterol for Maintenance and Reliever Therapy Among Patients With Poorly Controlled Asthma: A Systematic Review and Meta-analysis. JAMA Netw Open 2022;5(3):e220615
NHS England. The National Capabilities Framework for Professionals who care for Children and Young People with Asthma. 2025
Electronic Medicine Compendium (EMC). Symbicort, 100 micrograms/3 micrograms/actuation pressurised inhalation, suspension. Last updated May 2023
BEAT Asthma. Consensus recommendation for the practical application of the NICE/BTS/SIGN 2024 asthma guidance on MART therapy in children and young people. November 2025
UK Government. Medicines and Healthcare Products regulatory Agency (MHRA). Off-label or unlicensed use of medicines: prescribers’ responsibilities. 2014