Asthma Stepwise Therapy Management
The most effective approach to asthma management is a stepwise therapy based on severity, with inhaled corticosteroids (ICS) as the cornerstone of treatment for persistent asthma and combination ICS/formoterol as both maintenance and reliever therapy for moderate to severe asthma. 1
Classification of Asthma Severity
Asthma severity is classified into four categories that guide initial treatment:
| Severity | Symptoms | Nighttime Awakenings | SABA Use | Lung Function |
|---|---|---|---|---|
| Intermittent | ≤2 days/week | ≤2 times/month | ≤2 days/week | FEV1 >80% predicted |
| Mild Persistent | >2 days/week but not daily | 3-4 times/month | >2 days/week but not daily | FEV1 >80% predicted |
| Moderate Persistent | Daily | >1 time/week but not nightly | Daily | FEV1 60-80% predicted |
| Severe Persistent | Throughout the day | Often 7 times/week | Several times per day | FEV1 <60% predicted |
Stepwise Approach for Ages ≥12 Years
Step 1: Intermittent Asthma
- Preferred: Short-acting beta-agonist (SABA) as needed
- Alternative (2020 update): Low-dose ICS-formoterol as needed 1
Step 2: Mild Persistent Asthma
- Preferred: Daily low-dose ICS plus as-needed SABA
- Alternative options:
Step 3: Moderate Persistent Asthma
- Preferred:
- Alternative: Medium-dose ICS alone or low-dose ICS plus leukotriene modifier, theophylline, or zileuton 1
Step 4: Moderate-to-Severe Persistent Asthma
- Preferred: Medium-dose ICS/formoterol as both maintenance and reliever therapy 1
- Alternative: Medium-dose ICS/LABA plus SABA as needed or medium-dose ICS plus leukotriene modifier/theophylline 1
Step 5: Severe Persistent Asthma
- Preferred: High-dose ICS/LABA plus SABA as needed
- Consider: Adding omalizumab for patients with allergies 1
Step 6: Very Severe Persistent Asthma
- Preferred: High-dose ICS/LABA plus oral corticosteroids
- Consider: Omalizumab for allergic asthma 1
Stepwise Approach for Children 5-11 Years
The approach is similar but with some key differences:
- SMART therapy (ICS/formoterol as both maintenance and reliever) is recommended for steps 3-4 1
- Dosing and medication options may differ
- Growth should be monitored with ICS use 1
Important Considerations
SMART Therapy Considerations
- Formoterol is the preferred LABA due to its rapid onset of action
- Salmeterol should not be used for SMART due to slower onset
- Studies primarily used budesonide/formoterol for SMART therapy 1
Stepping Up and Down
- Step up if inadequate control after checking inhaler technique, adherence, environmental triggers, and comorbidities
- Step down if asthma is well-controlled for at least 3 months 1
- Frequent use of SABA (>2 days/week) indicates inadequate control and need to step up 1
Monitoring Control
- Assess control at each visit using validated tools like Asthma Control Test or Asthma Control Questionnaire
- Monitor FEV1 or peak flow (80% or more of predicted/personal best indicates good control) 1
Pitfalls and Caveats
LABA Safety: LABAs should never be used as monotherapy for asthma due to increased risk of asthma-related death 1, 2
ICS Adherence: Poor adherence to regular ICS therapy is common and increases exacerbation risk. Consider SMART or as-needed ICS/SABA for patients with adherence issues 1
Growth Concerns: While there may be small, transient effects on growth with ICS in children, untreated asthma poses greater risks to health and development 1
Exacerbation History: Patients with ≥2 exacerbations requiring oral steroids in the past year should be treated as having persistent asthma even if symptoms suggest intermittent asthma 1
Beta-Agonist Overuse: Using more than one SABA canister per month indicates poor control and need for increased controller therapy 1
The stepwise approach is meant to guide clinical decision-making but should be adjusted based on individual response to therapy. Regular reassessment of control and adjustment of therapy is essential for optimal asthma management.