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Difficult to manage asthma is asthma that either the patient or the clinician finds difficult to manage.

A patient with difficult to manage asthma has daily symptoms and regular exacerbations despite apparently best treatment.  There are two main groups of patients with difficult to manage asthma:

  •  People whose asthma has been controlled in the past but who have now lost control
  •  People whose asthma has never been controlled 

Investigations and management should aim to:

  • Identify when asthma control is lost / has never been achieved by prompt and effective monitoring using the SIMPLES mnemonic to help
  • Gain/regain control and then maintain control of asthma with effective, well- tolerated treatment


Download our practical "how to" guide in a variety of languages, validated and adapted by our member groups here  Available in:

  • English                                    
  • French
  • German
  • Greek
  • Italian
  • Polish
  • Portuguese
  • Romanian
  • Russian
  • Spanish
  • Turkish


Tools, resources and references

These resources are linked to the difficult to manage asthma desktop helper and are listed in the order of its recommendations.

Click here to view the practical tools and resources

Difficult to manage asthma desktop helper references

Referral letter for difficult to manage asthma (UK version)
Referral letter for difficult to manage asthma (outside UK)

Video describing how to use SIMPLES in practice by Dr Dermot Ryan

Primary Care Respiratory Journal September 2013 Ryan D, Murphy A, Stallberg B, Baxter N, Heaney LG. ‘SIMPLES’: a structured primary care approach to adults with difficult asthma. Prim Care Respir J 2013;22(3):365-373. DOI: 10.4104/pcrj.2013.00075

Difficult to manage asthma - Position Paper for policy makers


Advisory panel and authors

Clinical co-chairs of project:  Prof Stephen Holgate and Dr Dermot Ryan (UK)
Clinical authors of desktop helper: Prof Armando Brito de Sá (Portugal), Prof Pascal Chanez (France), Dr Javiera Corbalan (Chile), Assoc Prof Jaime Correia de Sousa (Portugal), Breda Flood (EFA), Prof Liam Heaney (Northern Ireland), Prof Michael Hyland (UK), Prof Jan Lötvall (EAACI), Dr Björn Ställberg (Sweden), Dr Scott Wagers (Belgium), Dr Osman Yusuf (Pakistan)
SIMPLES acronym: Anna Murphy
Writer and editor: Susan Mayor, Siân Williams


This programme has been taught in a Teach the Teacher programme


Adaptation for the Dutch context published:

Honkoop PJ, Pinnock H, Kievits-Smeets RMM, Sterk PJ, Dekhuijzen PNR, in ’t Veen JCCM. Adaptation of a difficult-to-manage asthma programme for implementation in the Dutch context: a modified e-Delphi. npj Prim Care Respir Med [Internet]. 2017;27(May 2016):16086. Available from:

Highlighted in Romanian policy journal

Journal and article January 2019