Is school based directly observed therapy (DOT) in asthma always effective? (The Good, the Bad and the Ugly of DOT). Author: S Frost, J Bennett, T Evans, S Stone, P Nagakumar Introduction: Inhaled steroids reduce asthma related symptoms and asthma attacks (Wennergren:1996). However, the adherence to inhaled steroids measured by electronic monitoring device is <50% (Chan:2015). School based directly observed therapy (DOT) has been shown to be effective in improving asthma control (Halterman:2012). We describe the experience of DOT over a 3 year period. Although this review only involved a small sample of children, it clearly demonstrates our past and current experiences of DOT with children and young people with difficult asthma managed at a regional tertiary children’s hospital’s difficult asthma service. Methods: A retrospective study looking at evidence over a three year period, where a decision to start DOT was made following a structured difficult asthma assessment. All patients were on high dose asthma therapies and had >4 asthma exacerbations in the previous year. All the patients were eligible for Omalizumab. Information was gleaned from: Medical and nursing records, lung function results, Mini paediatric quality of life questionnaires, asthma control test ,the number of unscheduled visits with health care, the number of exacerbations, time missed from school, adherence data from electronic monitoring device and /or structured inpatient assessment of asthma. Results: DOT was initiated in 3/8 recommended patients. All the 3 patients were males, aged 10yr, on DOT therapy for 4 months to 3 yr. The patient who was on DOT for four months demonstrated no improvement with their asthma control, a second on DOT for 12 months, demonstrated improvement in asthma control until school holidays, which resulted in asthma exacerbations and a return of poor quality of life . The third patient who has been on DOT for three years has demonstrated improved lung function, improved quality of life, no admissions to hospital and has enabled a reduction of add on treatment.FEV1 improved from 62% to 100% and asthma control test from 9 to 24 during this period. DOT in 5 patients was unable to be established due to lack of resources at the school (n= 3) and families refusing and therefore safeguarding issues were raised by the team. (n=2) . Conclusions/ implications for practice: In a subgroup of children with ‘difficult asthma’ due to poor adherence to asthma medications, DOT can help improve asthma control, and reduce asthma exacerbations. However, collaborative work with the school and the family is crucial. Alongside continued support to the schools and the families, alternative plans for school holidays for administration of asthma medications is necessary to reap the benefits of DOT. Chann et al (2015) The Effect of an electronic monitoring device with audivisual reminder function on adherence to inhaled corticosteroids and school attendance in children with asthma; a randomised controlled trial https://doi.org/10.1016/S2213-2600(15)00008-9 Halterman et al (2012) The school based preventative asthma care trial; results of a pilot studyhttps://www.ncbi.nlm.nih.gov/pubmed/22785264 Wennergren G, Kristjansson S, Strannegard I (1996) Decrease in hospitalisation for treatment of childhood asthma with increased use of anti-inflammatory treatment, despite an increase in prevalence of asthma. J.allergy Clinical Immunology. March 742 -748 .