What are the steps for stepping up therapy in patients with uncontrolled asthma on a low-dose Inhaled Corticosteroid (ICS)?

Stepping Up Therapy for Uncontrolled Asthma on Low-Dose ICS

The preferred step-up therapy for patients with uncontrolled asthma on low-dose inhaled corticosteroids (ICS) is to add a long-acting beta-agonist (LABA) rather than increasing the ICS dose. 1

Initial Assessment Before Stepping Up

Before making any changes to therapy, always:

• Check medication adherence
• Verify proper inhaler technique
• Assess environmental control measures
• Evaluate for comorbid conditions that may worsen asthma

Step-Up Algorithm for Patients on Low-Dose ICS

First-Line Option:

• Add a LABA to the current low-to-medium dose ICS 1
  • This combination provides better symptom control and lung function improvement than simply increasing ICS dose
  • Available as combination inhalers (e.g., fluticasone/salmeterol, budesonide/formoterol)
  • LABAs should NEVER be used as monotherapy without ICS due to safety concerns 2

Alternative Options (if LABA addition is not possible):

1. Increase ICS dose to medium range 1

   • Less effective for symptom control than adding LABA 3
   • May provide better protection against severe exacerbations 4

2. Add a leukotriene receptor antagonist (LTRA) 1

   • Similar efficacy to doubling ICS dose 3
   • May be particularly useful in patients with concurrent allergic rhinitis

3. Add theophylline 1

   • Similar efficacy to doubling ICS dose 3
   • Requires monitoring of serum levels
   • Higher risk of side effects than other options

Comparing Step-Up Options

LABA Addition vs. Increasing ICS Dose:

• LABA addition provides:
  • Better improvement in lung function 3, 5
  • Better symptom control 3
  • Reduced rescue medication use 4
• Increasing ICS dose may provide:
  • Better protection against severe exacerbations requiring oral steroids 4
  • Lower risk of respiratory hospitalizations 4

LABA vs. LTRA as Add-on:

• LABA addition is superior for improving lung function 3
• Both options may be comparable in reducing asthma exacerbations 3

Monitoring After Step-Up

• Schedule follow-up within 2-4 weeks to assess response 1
• Evaluate:
  • Symptom control
  • Lung function (spirometry or peak flow)
  • Frequency of rescue medication use
  • Exacerbations

Further Step-Up If Needed

If asthma remains uncontrolled after initial step-up:

1. Increase to medium-dose ICS + LABA 1
2. Consider adding a third controller medication (LTRA or theophylline) 1
3. Progress to high-dose ICS + LABA if still uncontrolled 1
4. Consider biologics (e.g., omalizumab) for appropriate patients with allergic asthma 1
5. Add oral corticosteroids as last resort 1

Important Cautions

• LABAs must always be used with ICS, never as monotherapy (black box warning) 2
• Higher doses of ICS may provide minimal additional benefit while increasing risk of systemic effects 1
• Theophylline requires monitoring of serum levels 1
• Omalizumab carries a small risk of anaphylaxis (0.09%) 1
• Patients using SABA more than twice weekly for symptom relief generally indicates inadequate control 1

Emerging Options

The SABA-ICS combination approach (e.g., albuterol-budesonide) represents a newer option that may help address poor adherence to regular ICS therapy, particularly in mild asthma 6.