What are the guidelines for managing mild asthma?

From the Guidelines

Managing mild asthma involves a stepwise approach focused on symptom control and preventing exacerbations, with the recommended treatment including a low-dose inhaled corticosteroid (ICS) and as-needed short-acting beta-agonist (SABA) for quick-relief therapy, as conditionally recommended by the Expert Panel with moderate certainty of evidence 1.

Key Components of Mild Asthma Management

• A low-dose inhaled corticosteroid (ICS) such as budesonide (200-400 mcg daily) or fluticasone (100-250 mcg daily) as maintenance therapy
• A short-acting beta-agonist (SABA) like albuterol (also called salbutamol) as needed for symptom relief
• Alternatively, some patients may use the newer approach of as-needed low-dose ICS-formoterol combination (like budesonide-formoterol) which serves as both maintenance and rescue therapy

Additional Recommendations

• Patients should have a written asthma action plan that outlines daily management and how to recognize and respond to worsening symptoms, as suggested by the expert panel report 3 (EPR-3) guidelines 1
• Environmental trigger avoidance is crucial, including reducing exposure to allergens, irritants, and tobacco smoke
• Regular follow-up appointments every 3-6 months help assess symptom control and adjust medications if needed
• Proper inhaler technique should be demonstrated and checked regularly, as incorrect usage significantly reduces medication effectiveness

Rationale

These approaches work by reducing airway inflammation (the underlying cause of asthma) with ICS while providing bronchodilation with beta-agonists when needed for symptom relief, as supported by the 2020 focused updates to the asthma management guidelines 1 and other studies 1.

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. Lung function (mean forced expiratory volume in 1 second [FEV1] or morning peak expiratory flow [AM PEF]), beta-agonist use, and asthma symptoms should be carefully monitored during withdrawal of oral corticosteroids.

The guidelines for managing mild asthma are not directly addressed in the provided drug label. However, it can be inferred that patients with mild asthma may require:

• Monitoring of lung function, beta-agonist use, and asthma symptoms
• Supplementary systemic corticosteroids during periods of stress or severe asthma attacks
• Slow withdrawal of oral corticosteroids to minimize the risk of adrenal insufficiency or other systemic effects 2

From the Research

Guidelines for Managing Mild Asthma

• The Global Initiative for Asthma 2019 strategy for the management of asthma recommends a significant departure from traditional treatments, suggesting that short-acting beta agonists (SABAs) should not be used as monotherapy for patients with mild asthma symptoms due to safety concerns and poor outcomes 3.
• Instead, the use of a combined inhaled corticosteroid-fast acting beta agonist as a reliever is recommended, as it has been shown to be superior to SABA in ensuring asthma control and non-inferior to budesonide maintenance therapy in preventing exacerbations 4.
• Anti-inflammatory reliever therapy with budesonide-formoterol, given on an as-needed basis, has been found to be effective in managing mild asthma, reducing the risk of asthma morbidity and mortality 5.
• Inhaled corticosteroids (ICSs) have been recommended as a maintenance treatment for all asthma patients, and ICS-containing reliever medication has been found to be superior to SABA as reliever alone, and equivalent to maintenance ICS and SABA as reliever, in reducing risks of severe asthma exacerbations 5.

Treatment Options

• Combined anti-inflammatory and reliever medications in a single inhaler, such as salmeterol/fluticasone propionate, have been found to be effective in improving lung function and symptoms, and are a cost-effective option for the maintenance treatment of patients with asthma 6.
• The combination of ICS/formoterol has been found to be superior to SABA as reliever alone, and equivalent to maintenance ICS and SABA as reliever, in reducing risks of severe asthma exacerbations 5.
• Two inhaled corticosteroid/long-acting beta-agonist combinations, fluticasone propionate/salmeterol and budesonide/formoterol, have been found to improve small-airway function in mild asthmatics, with onset of action detected as early as 5 minutes after dosing 7.

Key Recommendations

• SABAs should not be used as a reliever without ICS, due to the risk of increased asthma morbidity and mortality 3, 5.
• ICS/formoterol should be considered as a treatment option instead of maintenance ICS, to avoid the risk of patients reverting to SABA alone 5.
• Anti-inflammatory reliever therapy with budesonide-formoterol, given on an as-needed basis, is a recommended treatment option for managing mild asthma 4, 5.