What are the current guidelines for asthma treatment?

Current Asthma Treatment Guidelines

The cornerstone of asthma management is inhaled corticosteroids (ICS) as first-line controller therapy, with a stepwise approach based on symptom severity and control. 1

Stepwise Approach to Asthma Management

Step 1: Mild Intermittent Asthma

• Short-acting β2-agonists (SABA) as needed for symptom relief
• Consider low-dose ICS even in patients with mild symptoms as this can significantly improve lung function and reduce exacerbation risk 2

Step 2: Mild Persistent Asthma

• Regular low-dose ICS (equivalent to fluticasone propionate 100-250 μg/day) 3
• SABA as needed for breakthrough symptoms
• ICS monotherapy can achieve asthma control in approximately 70% of steroid-naive patients with mild to moderate asthma 4

Step 3: Moderate Persistent Asthma

• Low-dose ICS/LABA (long-acting β2-agonist) combination
  • Fluticasone propionate/salmeterol (100/50 μg, 250/50 μg) twice daily 5
  • Once-daily formulations like fluticasone furoate/vilanterol have shown better real-world control with fewer SABA canisters used and lower exacerbation rates compared to twice-daily combinations 6
• Alternative: Medium-dose ICS

Step 4: Severe Persistent Asthma

• Medium to high-dose ICS/LABA combination
• Consider adding a third controller medication if needed

Step 5: Very Severe Persistent Asthma

• High-dose ICS/LABA combination
• Consider oral corticosteroids
• Referral to specialist care

Rescue Therapy for Exacerbations

• Short course of oral corticosteroids (prednisolone 30-60 mg daily for 1-3 weeks in adults) 1
• Indications for oral steroids include:
  • Progressive worsening of symptoms
  • Peak expiratory flow (PEF) below 60% of patient's best
  • Sleep disturbance due to asthma
  • Diminishing response to inhaled bronchodilators
  • Emergency use of nebulized treatments

Acute Severe Asthma Management

1. High-dose inhaled β2-agonists (nebulized salbutamol 5 mg or terbutaline 10 mg)
2. Systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg)
3. Oxygen therapy to maintain saturation 94-98%
4. Consider adding nebulized ipratropium bromide (0.5 mg) in severe cases
5. Consider IV aminophylline or IV β2-agonists if no response to initial treatment 1

Monitoring and Follow-up

• Regular assessment of symptom control
• PEF monitoring
• Adjustment of therapy based on control
• Goals of treatment:
  • Minimal or no chronic symptoms including nocturnal symptoms
  • Minimal exacerbations
  • Minimal need for rescue bronchodilators
  • No limitation of activities
  • PEF circadian variation <20%
  • PEF ≥80% of predicted or personal best 1

Self-Management Education

• Written asthma action plan
• Regular medication review
• Proper inhaler technique training
• Recognition of worsening symptoms
• When to seek medical help 1

Important Considerations

• Avoid undertreatment: Even mild asthma benefits from regular ICS treatment 2
• Dosing optimization: Standard daily dose of ICS (fluticasone propionate 200-250 μg or equivalent) achieves 80-90% of maximum therapeutic benefit 3
• Medication adherence: Critical for achieving and maintaining control
• Inhaler technique: Regular review and correction of technique
• Comorbidities: Address conditions that may worsen asthma control

Criteria for Specialist Referral

• Diagnostic uncertainty
• Suspected occupational asthma
• Poor response to standard therapy
• Frequent exacerbations despite appropriate therapy
• Life-threatening asthma attack
• Need for specialized treatments 1

Cautions

• Avoid sedation in acute asthma as it is contraindicated
• Antibiotics should only be given if bacterial infection is present
• Monitor for oral candidiasis with ICS use and advise patients to rinse mouth after inhalation 5
• Be alert for potential side effects with high-dose ICS including adrenal suppression, decreased bone mineral density, and increased risk of glaucoma/cataracts 5