From the Guidelines
The treatment of chronic persistent asthma should involve a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone therapy, with the addition of a long-acting beta-agonist (LABA) for moderate to severe persistent asthma, as recommended by the Journal of Allergy and Clinical Immunology 1. For mild persistent asthma, start with a low-dose ICS such as fluticasone 88-220 mcg or budesonide 180-360 mcg twice daily.
- Key considerations for treatment include:
- Proper inhaler technique to ensure medication effectiveness
- Regular follow-up every 3-6 months to assess control and adjust therapy as needed
- Step-up therapy if symptoms persist and step-down if well-controlled for 3 months For moderate persistent asthma, use a combination of ICS plus a LABA like fluticasone/salmeterol (Advair) 250/50 mcg twice daily or budesonide/formoterol (Symbicort) 160/4.5 mcg twice daily, as this is the preferred treatment according to the Journal of Allergy and Clinical Immunology 1.
- Additional treatment options for severe persistent asthma include:
- High-dose ICS/LABA combinations
- Consideration of adding a long-acting muscarinic antagonist like tiotropium 2.5 mcg daily
- Oral systemic corticosteroids on a regularly scheduled, long-term basis, with the goal of using the lowest possible dose and monitoring closely for adverse side effects, as recommended by the Journal of Allergy and Clinical Immunology 1. All patients should have a rescue inhaler such as albuterol 90 mcg 2 puffs every 4-6 hours as needed.
- The medications work by:
- Reducing airway inflammation (ICS)
- Relaxing bronchial smooth muscle (LABA)
- Blocking cholinergic bronchoconstriction (tiotropium) It is essential to prioritize the patient's quality of life, morbidity, and mortality when making treatment decisions, and to consider consultation with an asthma specialist for patients with severe persistent asthma, as recommended by the Journal of Allergy and Clinical Immunology 1.
From the FDA Drug Label
XOLAIR is an injectable prescription medicine used to treat: moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with asthma medicines called inhaled corticosteroids.
Treatment of chronic persistent asthma: Omalizumab (XOLAIR) is used to treat moderate to severe persistent asthma in people 6 years of age and older whose asthma symptoms are not well controlled with inhaled corticosteroids.
- It is essential to note that XOLAIR should be used in conjunction with other asthma medications and not as a replacement for them.
- Patients should continue to take their other asthma medications as prescribed by their healthcare provider unless otherwise instructed. 2
From the Research
Treatment Options for Chronic Persistent Asthma
- Inhaled corticosteroids (ICS) are considered the cornerstone of asthma therapy and are the most effective anti-inflammatory medication for the treatment of persistent asthma, regardless of its severity 3.
- The Global Initiative for Asthma guidelines recommend the use of ICS, with a proposed reclassification of ICS doses based on a "standard daily dose" of 200-250 μg of fluticasone propionate or equivalent 4.
- Combination therapy with ICS and a long-acting beta2-agonist is recommended as initial maintenance therapy for patients with sufficient disease severity 3.
Comparison of Treatment Options
- ICS are more effective than leukotriene receptor antagonists (LTRAs) as initial maintenance therapy, with studies showing greater improvements in lung function and asthma control 3.
- The combination of an inhaled steroid plus a long-acting beta-agonist bronchodilator may be a more effective option for the management of persistent asthma than treatment with a single-controller agent alone (ICS or LTRA) 3.
- Fluticasone propionate/formoterol fumarate in fixed-dose combination has demonstrated a good safety and tolerability profile and is an effective option for the treatment of persistent asthma 5.
Safety and Efficacy of Combination Therapies
- Salmeterol/fluticasone propionate is at least as effective in improving lung function and symptoms and is as well tolerated in patients with asthma as concurrent salmeterol plus fluticasone propionate 6.
- The fluticasone/formoterol combination has demonstrated a good safety and tolerability profile in trials of up to 1 year 5.
- Moderate-high daily ICS doses are associated with an increased risk of cardiovascular events, pulmonary embolism, and pneumonia, highlighting the importance of using the lowest effective ICS dose 7.