What is the treatment for asthma?

Treatment of Asthma: A Stepwise Approach

The cornerstone of asthma treatment is inhaled corticosteroids (ICS) for persistent asthma, with a stepwise approach based on severity, and short-acting beta agonists (SABA) for quick relief of symptoms. 1

Classification of Asthma

Asthma is classified into:

1. Intermittent asthma (Step 1)
2. Persistent asthma:
   • Mild (Step 2)
   • Moderate (Steps 3-4)
   • Severe (Steps 5-6)

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• Preferred: Inhaled short-acting beta agonist (SABA) as needed
• New recommendation: Consider as-needed low-dose ICS-formoterol or ICS-SABA combination instead of SABA alone, as this reduces exacerbation risk 2, 3, 4

Step 2: Mild Persistent Asthma

• Preferred: Daily low-dose inhaled corticosteroid plus as-needed SABA
• Alternative: Leukotriene receptor antagonist (montelukast), cromolyn, nedocromil, or theophylline 1

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose inhaled corticosteroid plus long-acting beta agonist (LABA) OR medium-dose inhaled corticosteroid
• Alternative: Low-dose inhaled corticosteroid plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred: Medium-dose inhaled corticosteroid plus LABA
• Alternative: Medium-dose inhaled corticosteroid plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• Preferred: High-dose inhaled corticosteroid plus LABA
• Consider: Adding omalizumab for patients with allergies 1

Step 6: Very Severe Persistent Asthma

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

Important Medication Considerations

Inhaled Corticosteroids (ICS)

• Most effective controller medication for persistent asthma
• Improve symptoms, reduce exacerbations, and decrease need for rescue medications
• Systemic effects typically not clinically significant except with long-term high-dose use
• Common side effects: dysphonia, oral candidiasis (can be reduced with spacer use and mouth rinsing) 1

Long-Acting Beta Agonists (LABAs)

• WARNING: Should NEVER be used as monotherapy for asthma control
• Must ALWAYS be used in combination with ICS
• Associated with increased risk of severe exacerbations and deaths when used alone
• Effectiveness may be reduced in some ethnic populations, particularly Black patients 1, 5

Leukotriene Receptor Antagonists

• Montelukast (Singulair) - taken once daily for patients older than one year
• Zafirlukast (Accolate) - taken twice daily for patients seven years and older
• Advantages: ease of use, high compliance rates
• Good alternative for patients unable/unwilling to use inhaled corticosteroids 1, 6

Short-Acting Beta Agonists (SABAs)

• Most effective for rapid reversal of airflow obstruction and symptom relief
• Should be used only as needed for symptoms or before anticipated triggers
• Increasing use (more than twice weekly) indicates inadequate control and need to step up therapy 1

Management of Acute Exacerbations

For moderate to severe exacerbations:

1. High-flow oxygen to maintain saturation >92% 7
2. Frequent SABA treatments: Albuterol/salbutamol 5-10 mg nebulized every 15-30 minutes as needed 7
3. Add ipratropium bromide: 0.5 mg nebulized every 6 hours 7
4. Systemic corticosteroids:
   • Adults: 40-60 mg prednisone daily for 5-10 days
   • Children: 1-2 mg/kg/day for 3-10 days
   • No tapering necessary for short courses 1, 7

Monitoring and Follow-up

• Assess control based on:

  • Symptom frequency
  • Nighttime awakenings
  • Rescue medication use (>2 days/week indicates poor control)
  • Activity limitations
  • Lung function
  • Exacerbation history 7

• Step up if needed (first check adherence, inhaler technique, environmental control, and comorbidities)

• Step down if asthma is well-controlled for at least three months 1

Common Pitfalls to Avoid

1. Underestimating severity - leads to inadequate treatment 7
2. Inadequate corticosteroid dosing during acute attacks 7
3. Using LABAs without ICS - increases risk of severe exacerbations and death 1, 5
4. Poor inhaler technique - reduces medication effectiveness 1
5. Failure to address adherence issues - common cause of poor control 1, 8
6. Discharging patients too early without adequate follow-up plans 7

By following this stepwise approach and avoiding common pitfalls, most patients with asthma can achieve good symptom control and minimize the risk of exacerbations, hospitalization, and mortality.