Patients at increased risk of asthma-related death should be flagged in medical notes for frequent
monitoring; this was also recommended by the recent National Review of Asthma Deaths in the UK [55].
An early rapid increase in ICS now recommended for many action plans. Early guidelines recommended
doubling of ICS when asthma begins to worsen. However, doubling of ICS dose was found not to be
effective in three well-conducted randomised placebo-controlled trials in patients taking maintenance ICS
[56–58], except possibly if the doubling led to a high ICS dose [59]. Publication of these studies led to a
rapid shift in guidelines, with increasing doses of SABA considered to be sufficient until the exacerbation
was severe enough to warrant the use of systemic corticosteroids.