What are the treatment options for mild intermittent and severe asthma?

Treatment for Mild Intermittent and Severe Asthma

For mild intermittent asthma, short-acting beta-agonists (SABAs) as needed are recommended, while severe asthma requires high-dose inhaled corticosteroids plus long-acting beta-agonists, with consideration of add-on biologics like omalizumab for allergic phenotypes. 1

Mild Intermittent Asthma Treatment

First-line Therapy

• Short-acting beta-agonists (SABAs) as needed for symptom relief
  • Albuterol is preferred due to its excellent safety profile 1
  • Typical dosing: 2 puffs every 4-6 hours as needed
  • Should be used for quick symptom relief only, not regular daily use

Key Considerations

• Increasing use of SABAs (more than twice weekly) suggests inadequate control and need to step up therapy 1
• Recent evidence suggests that as-needed combination of ICS/SABA may be beneficial even in mild intermittent asthma to reduce exacerbation risk 2, 3
• Patients should be educated on proper inhaler technique and have an asthma action plan

Severe Asthma Treatment (Step 5-6)

Core Treatment (Step 5)

• High-dose inhaled corticosteroids (ICS) plus long-acting beta-agonists (LABAs) 1
  • LABAs (salmeterol, formoterol) should NEVER be used as monotherapy due to safety concerns 1, 4
  • LABAs must always be combined with ICS to reduce risk of severe exacerbations and death

Add-on Therapies (Step 6)

• Oral corticosteroids (when control cannot be achieved with other therapies)

  • Typically prednisone 40-60 mg daily in adults, with attempts to find minimum effective dose 1

• Omalizumab (Xolair) for allergic asthma 1

  • For patients ≥12 years with demonstrated hypersensitivity to inhaled allergens
  • Dosage: 150-375 mg subcutaneously every 2-4 weeks based on weight and IgE levels
  • Should be instituted in collaboration with an asthma specialist
  • Caution: Risk of anaphylaxis

• Additional controller options:

  • Leukotriene receptor antagonists (montelukast, zafirlukast)
  • Theophylline (requires serum level monitoring)
  • Other biologics (not covered in the evidence provided)

Treatment Algorithm

For Mild Intermittent Asthma:

1. Start with as-needed SABA (albuterol)
2. Monitor frequency of SABA use
3. If using SABA more than twice weekly (except for exercise prevention), consider stepping up to Step 2 (mild persistent asthma) with low-dose ICS

For Severe Asthma:

1. Ensure high-dose ICS plus LABA is optimized
2. Assess adherence, inhaler technique, and environmental triggers
3. Consider add-on therapy based on phenotype:
   • For allergic asthma: Add omalizumab
   • For eosinophilic asthma: Consider biologics targeting IL-5 pathway
4. Add oral corticosteroids at lowest effective dose if control remains inadequate

Important Clinical Pearls

1. Safety warning: LABAs should never be prescribed as monotherapy due to increased risk of asthma-related death 1, 4

2. Exacerbation management: Short courses of oral corticosteroids (3-10 days) are effective for exacerbations without need for tapering 1

3. Newer evidence: Recent studies support as-needed ICS/formoterol as an alternative to daily ICS in mild asthma, which may improve adherence 1, 5

4. Ethnic considerations: Some populations, particularly Black patients, may have genetic variations affecting LABA response 1

5. Pregnancy considerations: Budesonide is the preferred ICS during pregnancy due to more safety data, but other ICS can be continued if patient was well-controlled before pregnancy 1

6. Monitoring: Regular assessment of symptom control, lung function, and exacerbation history is essential to guide step-up or step-down therapy

By following this stepwise approach based on asthma severity, most patients can achieve good symptom control and reduced risk of exacerbations.