Key Points

1. SA has one of the highest reported asthma mortality rates, despite availability of inhaled corticosteroids (ICS) in all sectors of the healthcare system. 
2. The cornerstone of asthma treatment remains ICS. 
3. Patients with so-called ‘mild’ asthma are at risk for acute exacerbations and death, and should have an ICS included in their management strategy. 
4. Early diagnosis and control of asthma will reduce morbidity and mortality, and most people with asthma can lead a normal life with optimal control. 
5. The combination of an ICS with a long-acting beta-2 agonist (LABA) may control asthma with a lower maintenance dose of the ICS, and is recommended for most asthma patients. 
6. Patients with infrequent symptoms (less than 4 - 5 days a week) can be safely treated with an as-needed combination of ICS-formoterol. 
7. Where possible, the combination ICS and formoterol, rather than salbutamol alone, should be recommended for acute symptom relief, particularly in patients not on long-term ICS-LABA. 
8. The complacency with frequent salbutamol usage needs to be addressed by education and increased and regular use of an ICS. 
9. Biologic therapies (monoclonal antibodies directed towards IgE, interleukin-5/5-receptor (IL-5/5r), interleukin-4 receptor (IL-4r), etc.) are increasingly becoming available and need to be prudently prescribed after specialist review and clinical phenotyping. 
10. Slow-release theophylline should be considered only as an add-on fourth-line controller. 
11. Long-term use of oral corticosteroids is strongly discouraged owing to their severe side-effect profile.
12. Bronchial thermoplasty may be considered for severe or difficult-to-control patients with asthma on optimal medical treatment at a specialist referral centre. 
13. Home nebulisers are discouraged for the control of asthma and are not a substitute for optimal control with recommended treatment strategies. 
14. Inhaler technique and adherence must be addressed at every consultation before making any change in drug therapy. Poor technique is one of the most common causes of poor asthma control. 
15. Lung function should be measured annually in patients with asthma to objectively measure lung function impairment. At each clinic visit, a simple and validated scoring method such as the Asthma Control Test (ACT) should be used to determine current asthma control. 
16. Where possible, patient preference should be considered in the selection of inhaler device (dry powder or pressurised metered dose inhaler (pMDI)). Adequate instruction in inhaler technique is essential and should be checked at every visit. 
17. Well-controlled asthma does not appear to be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). Poor asthma control requiring the use of oral corticosteroids may increase the risk for COVID-19 disease.

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Guidelines for the management of asthma in adults and adolescents, South African Thoracic Society, 2021