From the Guidelines
The stepwise approach to asthma treatment involves progressively increasing therapy based on symptom control and risk assessment, with the goal of minimizing medication side effects while maximizing symptom control and reducing exacerbation risk. For Step 1 (intermittent asthma), as-needed short-acting beta-agonists (SABA) like albuterol 2 puffs every 4-6 hours as needed are recommended 1. Step 2 introduces daily low-dose inhaled corticosteroids (ICS) such as fluticasone 88mcg 1-2 puffs twice daily, with SABA for rescue. Step 3 adds a long-acting beta-agonist (LABA) like formoterol to low-dose ICS, often in combination inhalers like Symbicort (budesonide/formoterol) or Advair (fluticasone/salmeterol) 1.
Key Components of Asthma Management
- Assessing and monitoring asthma severity and control
- Identifying precipitating factors for episodic symptoms
- Identifying comorbid conditions that may impede asthma management
- Assessing the patient’s knowledge and skills for self-management
- Instructing patients to monitor their asthma control in an ongoing manner
Step 4 increases to medium-dose ICS-LABA combinations. Step 5 refers patients to specialists and may add biologics like omalizumab, mepolizumab, or benralizumab for severe eosinophilic asthma. Step 6 includes oral corticosteroids like prednisone for severe uncontrolled asthma. Throughout all steps, patients should have an asthma action plan, proper inhaler technique education, and regular follow-up to assess control 1.
Importance of Regular Monitoring
Regular monitoring of asthma control is crucial to guide decisions for maintaining or adjusting therapy. This can be achieved through symptom monitoring or peak flow monitoring, with evidence suggesting similar benefits for both approaches 1.
Treatment Goals
The primary goals of asthma treatment are to achieve and maintain control of symptoms, minimize the risk of exacerbations, and optimize quality of life. By following the stepwise approach to asthma treatment, healthcare providers can help patients achieve these goals and improve their overall health outcomes.
From the FDA Drug Label
These patients should also be instructed to carry a warning card indicating that they may need supplementary systemic corticosteroids during periods of stress or a severe asthma attack. Patients requiring oral corticosteroids should be weaned slowly from systemic corticosteroid use after transferring to Wixela Inhub® Prednisone reduction can be accomplished by reducing the daily prednisone dose by 2.5 mg on a weekly basis during therapy with Wixela Inhub®
The asthma stepwise approach to treatment is not directly addressed in the provided drug label. However, it can be inferred that the treatment approach involves:
- Weaning patients off oral corticosteroids and transferring them to Wixela Inhub
- Monitoring lung function, beta-agonist use, and asthma symptoms during withdrawal of oral corticosteroids
- Reducing prednisone dose by 2.5 mg on a weekly basis during therapy with Wixela Inhub
- Observing patients for signs and symptoms of adrenal insufficiency and other systemic corticosteroid effects 2
From the Research
Asthma Stepwise Approach to Treatment
The stepwise approach to asthma treatment involves a gradual increase or decrease in treatment based on the patient's symptoms and response to therapy 3, 4, 5, 6.
- The National Heart Lung and Blood Institute guidelines provide a stepwise approach to pharmacologic therapy, with corticosteroid therapy being the most effective anti-inflammatory treatment 3.
- The treatment steps include:
- Step 1: Intermittent asthma - as-needed short-acting β2-agonists (SABAs) for rescue therapy 5.
- Step 2: Mild persistent asthma - daily low-dose inhaled corticosteroids (ICS) plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy 5.
- Step 3 and 4: Moderate persistent asthma - formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) 5.
- Step 5: Moderate-severe persistent asthma - add-on long-acting muscarinic antagonists for individuals whose asthma is not controlled by ICS-formoterol therapy 5.
Treatment Options
- Combination treatment with inhaled corticosteroids (ICS) and long-acting beta2-adrenergic (LABA) bronchodilators, such as salmeterol/fluticasone propionate, provides greater asthma control than increasing the ICS dose alone 3, 7.
- Salmeterol/fluticasone propionate is a fixed-dose combination inhalation agent that improves lung function and asthma symptoms to a greater extent than monotherapy with ICS or other treatments 7.
- The 2019 Global Initiative for Asthma (GINA) guidelines recommend that all asthma patients be treated with inhaled corticosteroids taken daily or as needed, and that treatment be escalated or de-escalated based on symptom control 6.
Considerations
- Patient adherence to treatment can be improved with the convenience of a combination product, such as a single inhaler containing both ICS and LABA 3.
- The stepwise approach to asthma treatment should take into account the individual patient's symptoms, lung function, and quality of life, as well as the underlying mechanisms of the disease 4.
- A reassessment of the conventional stepping approach to management of asthma may be needed, with a focus on setting therapeutic goals for each individual and associating them with the treatable traits of asthma 4.