Asthma may cause anything from trivial symptoms to intractable breathlessness and treatment needs to be tailored accordingly. To provide a rational and easily applicable approach to prescribing for asthma, most clinical guidelines on asthma management rank the drugs available in hierarchical order, simplified in a series of steps.1 ,2 For the British guidelines these range from a β agonist as required (step 1) to the need for oral corticosteroids (step 5).1 Patients can be started at any step and, indeed, if their asthma is poorly controlled may well be advised to start on oral corticosteroids and reduce treatment when control is achieved. The guidelines do not mean that all patients with asthma of a given severity should be treated in an identical fashion, since patients clearly vary in their response to drugs. What the stepped approach is attempting to do is to suggest a hierarchy in which treatment is most likely to provide the best value for a patient with asthma of a given severity.

Fortunately most patients lie towards the mild end of the asthma spectrum and can be managed with an occasional β agonist or regular prophylactic treatment with low dose inhaled corticosteroid or a cromone. In a recent community survey in Nottinghamshire only 16% of patients were on step 3 or above,3 a relatively small proportion of the asthmatic population but still some three quarters of a million people in the UK. Furthermore, these are the patients with most morbidity and hospital admissions and who consume the most medical time and resources,4 ,5 and the figure quoted may well be an underestimate of the number of patients who should have been on step 3 or above. Determining which options should be available at step 3 has implications for a large number …