What is the stepwise approach for managing asthma?

Stepwise Approach for Managing Asthma

The stepwise approach to asthma management involves assessing severity to initiate therapy and monitoring control to adjust therapy, with treatment progressively stepped up to achieve control and stepped down when possible after maintaining control for at least 3 months. 1

Assessment of Asthma Severity and Control

Classification of Asthma Severity (for initiating treatment)

Adults and Children ≥12 Years:

• Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, normal FEV1, 0-1 exacerbations/year
• Mild Persistent: Symptoms >2 days/week but not daily, 3-4 nighttime awakenings/month, normal FEV1, 0-1 exacerbations/year
• Moderate Persistent: Daily symptoms, >1 nighttime awakening/week but not nightly, FEV1 60-80% predicted, ≥2 exacerbations/year
• Severe Persistent: Symptoms throughout the day, frequent nighttime awakenings, FEV1 <60% predicted, ≥2 exacerbations/year 1

Assessing Asthma Control (for adjusting therapy)

Components of Control:

• Well Controlled: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, no interference with activity, SABA use ≤2 days/week, FEV1 >80% predicted
• Not Well Controlled: Symptoms >2 days/week, 1-3x/week nighttime awakenings, some activity limitation, SABA use >2 days/week, FEV1 60-80% predicted
• Very Poorly Controlled: Symptoms throughout the day, ≥4x/week nighttime awakenings, extremely limited activity, SABA use several times daily, FEV1 <60% predicted 1

Stepwise Treatment Approach

Step 1

• Preferred: As-needed SABA
• Alternative: Low-dose ICS taken whenever SABA is taken

Step 2

• Preferred: Low-dose daily ICS
• Alternative: LTRA, theophylline, or cromolyn

Step 3

• Preferred: Low-dose ICS + LABA OR medium-dose ICS
• Alternative: Low-dose ICS + LTRA, theophylline, or zileuton

Step 4

• Preferred: Medium-dose ICS + LABA
• Alternative: Medium-dose ICS + LTRA, theophylline, or zileuton

Step 5

• Preferred: High-dose ICS + LABA
• Alternative: Consider omalizumab for patients with allergies

Step 6

• Preferred: High-dose ICS + LABA + oral corticosteroids
• Alternative: Consider omalizumab for patients with allergies 1

Key Principles for Treatment Adjustment

1. Stepping Up:

   • Check inhaler technique, adherence, environmental control, and comorbidities before stepping up
   • For not well-controlled asthma: Step up 1 level and reevaluate in 2-6 weeks
   • For very poorly controlled asthma: Consider short course of oral corticosteroids and step up 1-2 levels

2. Stepping Down:

   • Consider stepping down if asthma is well-controlled for at least 3 months
   • Gradually reduce ICS dose by 25-50% at 2-3 month intervals
   • For combination therapy, reduce ICS dose first while maintaining LABA 1

3. Monitoring:

   • Schedule follow-up visits at 2-6 week intervals when initiating therapy or stepping up
   • Schedule visits at 1-6 month intervals after asthma control is achieved
   • Consider 3-month interval visits if step-down is anticipated 1

Special Considerations

Referral to Specialist

Consider referral if:

• Patient has difficulty achieving or maintaining control
• Patient required >2 bursts of oral corticosteroids in 1 year
• Patient has an exacerbation requiring hospitalization
• Step 4 care or higher is required (Step 3 for children 0-4 years)
• Immunotherapy or omalizumab is being considered 1

Common Pitfalls to Avoid

1. Underestimating severity: Both patients and physicians tend to underestimate symptom severity or overestimate control level. Use validated assessment tools rather than relying solely on patient perception 1

2. Inadequate follow-up: Treatment changes should always be followed by scheduled reviews using evidence-based assessment tools 2

3. Not addressing adherence issues: Poor adherence to therapy, particularly to inhaled corticosteroids, is a common reason for poor response 3

4. Overlooking comorbidities: Unidentified factors including allergens, occupational sensitizers, dietary additives, drugs, gastroesophageal reflux, or upper airway disease may contribute to poor control 3

5. Assuming symptom control equals risk control: Asthma symptom control doesn't always equate to elimination of exacerbation risk, particularly in severe asthma 1

The stepwise approach provides a framework for asthma management, but treatment decisions should ultimately be based on the individual patient's response to therapy, with the goal of achieving and maintaining control while minimizing medication side effects and long-term risks.