What is the recommended treatment for asthma?

Asthma Treatment: A Stepwise Approach

Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment, with combination ICS and long-acting beta-agonist (LABA) therapy recommended for moderate to severe asthma that is not controlled with ICS alone. 1

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• Short-acting beta-agonist (SABA) as needed for symptom relief
• Warning sign: Using SABA more than 2 days/week indicates inadequate control and need to step up 1

Step 2: Mild Persistent Asthma

• First choice: Low-dose ICS daily (e.g., beclomethasone 80-240 mcg, budesonide 180-600 mcg, fluticasone, mometasone) 1, 2
• Alternative: Leukotriene receptor antagonist (e.g., montelukast) - less effective than ICS but may have better compliance 1, 3

Step 3: Moderate Persistent Asthma

• First choice: Low-dose ICS plus LABA 1, 2
• Alternative: Medium-dose ICS or low-dose ICS plus leukotriene receptor antagonist 1

Step 4: Severe Persistent Asthma

• First choice: Medium-dose ICS plus LABA 1
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5: Very Severe Persistent Asthma

• First choice: High-dose ICS plus LABA 1
• Consider adding omalizumab for patients with allergies 1, 2

Step 6: Refractory Asthma

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

Key Treatment Principles

Efficacy of Medications

• ICS are the most potent and consistently effective long-term control medication for asthma 1, 2
• When ICS alone are insufficient, adding LABA is more effective than increasing ICS dose for patients ≥12 years 1, 2
• High-dose ICS shows no additional clinical benefit in most efficacy parameters compared to low or moderate doses but may have more safety concerns 4

Safety Considerations

• LABA should never be used as monotherapy for asthma control due to increased risk of asthma-related events 1, 5
• Always combine LABA with ICS for safety 2, 5
• Monitor for potential side effects of ICS including oral thrush and dysphonia 2
• Advise patients to rinse their mouth after using ICS to reduce risk of oral thrush 2

Monitoring and Adjusting Treatment

• Assess control regularly:
  • Well-controlled: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, no interference with activity, SABA use ≤2 days/week 1
  • Not well-controlled: Symptoms >2 days/week, nighttime awakenings 1-3x/week, some activity limitation, SABA use >2 days/week 1
• Step up if needed after checking adherence, inhaler technique, and comorbidities 1
• Consider stepping down if asthma is well-controlled for at least 3 months 1, 2

Exercise-Induced Asthma

• SABA 15-30 minutes before exercise 2
• For patients ≥15 years with frequent exercise-induced symptoms, LABA (salmeterol) 30-60 minutes before exercise provides up to 12 hours protection 2

Common Pitfalls to Avoid

• Don't delay starting ICS in patients with persistent symptoms
• Don't use LABA without ICS - this increases risk of serious asthma-related events 5
• Don't rely solely on SABA for persistent asthma - increasing use indicates poor control 1
• Don't overlook proper inhaler technique - poor technique reduces medication effectiveness 2
• Don't continue same therapy when control is inadequate - step up according to guidelines 1

Special Considerations

• Combination therapy with ICS/LABA has improved compliance compared to separate inhalers 6
• Recent evidence supports ICS/formoterol as both maintenance and reliever therapy in some patients 7
• For severe exacerbations, oral systemic corticosteroids are recommended 1

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