From the Guidelines
The treatment of asthma exacerbations should follow a stepwise approach based on severity, with initial management including inhaled short-acting beta-agonists (SABA) and systemic corticosteroids for moderate to severe exacerbations. According to the most recent and highest quality study 1, primary treatment consists of administration of oxygen, inhaled b2-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation.
Key Components of Treatment
- Inhaled SABA like albuterol (2-4 puffs every 20 minutes for up to 1 hour) or via nebulizer (2.5-5 mg every 20 minutes for 1 hour) to address bronchoconstriction
- Systemic corticosteroids, typically prednisone 40-60 mg orally daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg/day), to reduce inflammation
- Oxygen therapy to maintain oxygen saturation ≥92%
- Consideration of adding ipratropium bromide to SABA treatment for severe exacerbations
- Magnesium sulfate may be considered for severe exacerbations unresponsive to initial treatments
Monitoring and Follow-Up
Continuous monitoring of vital signs, oxygen saturation, and response to therapy is essential. Patients should be discharged with a clear plan, including medications such as SABA, oral systemic corticosteroids, and consideration of initiating inhaled corticosteroids (ICS), along with referral for follow-up care and review of inhaler technique and environmental control measures 1.
Home Management
Early treatment by the patient at home is crucial, using a written asthma action plan that notes when and how to treat signs of an exacerbation, recognizing early indicators, adjusting medications, removing allergens or irritants, and monitoring response to treatment 1.
From the FDA Drug Label
SINGULAIR is not indicated for use in the reversal of bronchospasm in acute asthma attacks, including status asthmaticus. Patients should be advised to have appropriate rescue medication available. Therapy with SINGULAIR can be continued during acute exacerbations of asthma Patients who have exacerbations of asthma after exercise should have available for rescue a short-acting inhaled β-agonist.
The treatment orders for managing asthma exacerbations are not directly addressed in the provided drug labels. However, it is mentioned that SINGULAIR is not indicated for use in the reversal of bronchospasm in acute asthma attacks, and patients should have appropriate rescue medication available, such as a short-acting inhaled β-agonist. Additionally, therapy with SINGULAIR can be continued during acute exacerbations of asthma 2, 2, 2.
- Key points:
- SINGULAIR is not for acute asthma attacks
- Have rescue medication available
- Continue SINGULAIR during exacerbations
- Use short-acting inhaled β-agonist for rescue
From the Research
Treatment Orders for Managing Asthma Exacerbations
- The primary goal of treatment is to reduce inflammation and prevent exacerbations, with corticosteroids being the mainstay in asthma therapy 3
- For patients with mild to moderate asthma, optimizing the dose of inhaled corticosteroids before considering the addition of a long-acting beta 2-agonist is recommended 4
- Combination therapy with inhaled corticosteroids and long-acting beta 2-agonists is suitable for patients with more severe asthma who require additional control 4
- Oral corticosteroids, such as prednisolone, can be effective in treating exacerbations of asthma, with a dose response shown to be significant for the difference between peak flows 5
- The use of oral prednisone versus intravenous methylprednisolone in equivalent doses has been found to be effective in treating acute asthma exacerbations in hospitalized children, with no difference in length of hospital stay between the two groups 6
Medication Options
- Inhaled corticosteroids, such as budesonide, are recommended as monotherapy for the majority of patients with asthma 3
- Combination therapy with albuterol and budesonide as a reliever has been shown to reduce asthma exacerbations and oral corticosteroid burden in patients with moderate-to-severe asthma 7
- Long-acting beta 2-agonists, such as salmeterol, can be added to inhaled corticosteroids for patients who require additional control 4
Treatment Strategies
- The use of as-needed short-acting β2-agonist (SABA) and inhaled corticosteroid (ICS) as an alternative reliever can reduce exacerbation risk and decrease oral corticosteroid burden 7
- Intervening with as-needed SABA-ICS during the window of opportunity to reduce inflammation during loss of asthma control can reduce exacerbation risk 7