What is the recommended treatment approach for adults with asthma?

Stepwise Approach to Asthma Management in Adults

The recommended treatment approach for adults with asthma is a stepwise strategy that begins with inhaled corticosteroids (ICS) as the cornerstone of therapy, with progressive addition of long-acting beta-agonists (LABAs) and other agents based on symptom control and exacerbation risk. 1

Core Treatment Principles

Step 1: Mild Intermittent Asthma

• Preferred treatment: As-needed short-acting beta-agonist (SABA) such as albuterol
• Use of SABA more than twice weekly indicates inadequate control and need for controller medication 2

Step 2: Mild Persistent Asthma

• Preferred treatment: Low-dose ICS (e.g., fluticasone 100-250 μg/day)
• Alternative options: Leukotriene receptor antagonists (LTRAs), cromolyn, nedocromil, or theophylline (less preferred) 1
• Note: Recent evidence suggests that even "low-dose" ICS achieves 80-90% of maximum therapeutic benefit 3

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose ICS plus LABA OR medium-dose ICS alone
• Alternative options: Low-dose ICS plus LTRA, theophylline, or zileuton 1
• Research shows combination ICS/LABA provides better asthma control than ICS plus montelukast 4

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Medium-dose ICS plus LABA
• Alternative options: Medium-dose ICS plus LTRA, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA
• Consider adding omalizumab for patients with allergies 1

Step 6: Very Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA plus oral corticosteroid
• Consider omalizumab for patients with allergies 1

Medication Classes and Their Roles

Inhaled Corticosteroids (ICS)

• Primary controller medication for persistent asthma
• Suppress virtually every step of inflammation 5
• Examples: fluticasone propionate, beclomethasone, budesonide
• Dosing should start at "standard dose" (200-250 μg fluticasone equivalent) which provides 80-90% of maximum benefit 3

Long-Acting Beta-Agonists (LABAs)

• Must never be used as monotherapy 1
• Always use in combination with ICS
• Provide superior control compared to increasing ICS dose alone 6
• Examples: salmeterol, formoterol

Combination ICS/LABA Inhalers

• Provide coverage for both inflammatory and bronchoconstrictive aspects of asthma
• Improve adherence through convenience of single inhaler 7
• Examples: fluticasone/salmeterol (Advair), budesonide/formoterol

Leukotriene Modifiers

• Alternative but not preferred therapy for mild persistent asthma
• Less effective than adding LABA to ICS in moderate-to-severe asthma 4
• Examples: montelukast, zafirlukast, zileuton

Biologics

• Omalizumab (anti-IgE): For severe allergic asthma
• Consider for steps 5-6 when patients have allergic sensitivity to relevant allergens 1

Treatment Adjustments

• Step up: If symptoms persist or exacerbations occur despite current therapy

  • First check: Adherence, inhaler technique, environmental control, comorbidities
  • Increase treatment according to stepwise approach

• Step down: If asthma is well-controlled for at least 3 months

  • Gradually reduce treatment to find minimum effective dose
  • Maintain ICS therapy even when symptoms improve

Monitoring and Assessment

• Use of SABA more than twice weekly for symptom relief indicates inadequate control 1
• Regular assessment of symptom control and exacerbation risk
• Monitor for medication side effects, particularly with high-dose ICS or oral corticosteroids

Common Pitfalls to Avoid

1. Using LABA without ICS - increases risk of severe exacerbations and mortality
2. Overreliance on SABA - indicates poor control and need for controller therapy
3. Inadequate ICS dosing - underdosing leads to poor control; overdosing increases side effect risk
4. Poor inhaler technique - reduces medication effectiveness
5. Failure to address comorbidities - allergies, GERD, rhinosinusitis can worsen asthma control

Remember that approximately 70% of patients can achieve good asthma control across severity strata with appropriate stepwise therapy 1, but this requires regular monitoring and adjustment of treatment based on symptom control and exacerbation risk.