What is the recommended treatment for reactive airway disease?

Treatment of Reactive Airway Disease

The recommended first-line treatment for reactive airway disease (RAD) is inhaled corticosteroids (ICS) for persistent symptoms, with short-acting beta agonists (SABAs) as needed for immediate symptom relief. 1

Initial Assessment and Treatment Approach

Step 1: Determine Severity

• Intermittent symptoms: Use SABA as needed only
• Persistent symptoms: Add controller medication (primarily ICS)

Step 2: Select Appropriate Medication

For Immediate Symptom Relief:

• Short-acting beta agonists (SABAs) such as albuterol
  • Used as rescue medication for all severity levels
  • Warning: Using SABAs more than twice weekly indicates inadequate control 1

For Persistent Symptoms (Controller Medications):

1. First-line: Low-dose inhaled corticosteroids

   • Preferred controller medication with strongest evidence 1, 2
   • Example: Fluticasone propionate (Flovent) is recommended as first-line ICS 1
   • ICS are the only currently available therapy that effectively suppresses airway inflammation 3

2. Alternative controllers (less effective than ICS):

   • Leukotriene receptor antagonists (e.g., montelukast)
   • Cromolyn sodium
   • Nedocromil
   • Theophylline 2, 1

Step-Up Therapy for Inadequate Control

Moderate Persistent Asthma

When symptoms remain uncontrolled on low-dose ICS:

• Preferred approach: Add long-acting beta agonist (LABA) to low-dose ICS 2, 1

  • Combination therapy (e.g., fluticasone/salmeterol) provides superior symptom control compared to doubling ICS dose 4, 5
  • This approach improves lung function without masking underlying inflammation 4

• Alternative approach: If LABA cannot be used, options include:

  • Increase to medium-dose ICS 1
  • Add leukotriene receptor antagonist 2
  • Add theophylline 2

Severe Persistent Asthma

• High-dose ICS plus LABA 1
• Consider adding other controllers if needed

Monitoring and Adjustment

Regular Assessment

• Evaluate symptom control, lung function, and medication side effects
• Consider stepping down therapy after 3 months of good control 1
• When reducing therapy, decrease ICS dose by 25-50% at each step 1

Common Pitfalls to Avoid

• Failure to step down therapy after achieving control
• Poor adherence to controller medications
• Improper inhaler technique
• Unidentified triggers or comorbidities

Special Considerations

Delivery Devices

• Metered-dose inhalers (MDIs) with spacers are recommended for initial treatment 1
• Proper inhaler technique is essential for effective medication delivery

Children

• Growth monitoring is important in children on ICS therapy 1
• Low-dose ICS is the preferred controller medication for children with persistent asthma 2

Treatment Goals

• Minimal or no chronic symptoms
• Minimal need for rescue medication
• No limitation of activities
• Maintenance of optimal pulmonary function
• Minimal medication side effects 1

While some cases of reactive airway disease may be refractory to conventional treatments, the evidence strongly supports starting with inhaled corticosteroids for persistent symptoms, with step-up therapy as needed based on symptom control.