What is the recommended treatment for asthma?

Recommended Treatment for Asthma

The recommended treatment for asthma follows a stepwise approach, with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma, and combination therapy with ICS plus long-acting beta-agonists (LABA) for moderate to severe persistent asthma. 1

Assessment and Classification

Before initiating treatment, assess asthma severity based on:

• Symptom frequency (daytime and nighttime)
• Rescue medication use
• Lung function (PEF or FEV1)
• Impact on daily activities

Asthma is classified into:

1. Intermittent
2. Mild persistent
3. Moderate persistent
4. Severe persistent

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• Preferred treatment: Short-acting beta-agonist (SABA) as needed
• Examples: Albuterol or terbutaline inhaler

Step 2: Mild Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroid (ICS)
• Alternative treatments: Leukotriene receptor antagonists (e.g., montelukast), cromolyn, nedocromil, or theophylline

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose ICS plus long-acting beta-agonist (LABA) OR
• Medium-dose ICS
• Alternative treatment: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Medium-dose ICS plus LABA
• Alternative treatment: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton

Step 5: Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA
• Consider adding omalizumab for patients with allergies

Step 6: Very Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA plus oral corticosteroid
• Consider omalizumab for patients with allergies

Medication Details

Inhaled Corticosteroids (ICS)

• First-line controller medication for persistent asthma
• Examples: Fluticasone propionate, budesonide, beclomethasone
• Dosing: Standard daily dose of fluticasone propionate is 200-250 μg, which achieves 80-90% of maximum therapeutic benefit 2
• Side effects: Oral candidiasis, dysphonia (advise rinsing mouth after use)

Long-Acting Beta-Agonists (LABA)

• Important safety note: LABAs should never be used as monotherapy for asthma control due to increased risk of severe exacerbations and deaths 1, 3
• Must be used in combination with ICS
• Examples: Salmeterol, formoterol
• Combination products (e.g., fluticasone/salmeterol) improve adherence and outcomes 4

Leukotriene Receptor Antagonists

• Alternative for mild persistent asthma in patients unable/unwilling to use ICS
• Examples: Montelukast, zafirlukast
• Advantages: Once-daily dosing (montelukast), high compliance rates
• Not for acute symptom relief 5

Acute Exacerbation Management

For acute exacerbations:

1. Short-acting beta-agonist (SABA) via nebulizer or inhaler with spacer
2. Systemic corticosteroids for moderate to severe exacerbations
3. Oxygen therapy to maintain saturation 92-95%
4. Consider ipratropium bromide for severe exacerbations 6

Stepping Down Therapy

Once asthma is well-controlled for at least 3 months:

1. If on combination therapy (ICS/LABA), stepping down to a lower dose of the combination is more effective than eliminating the LABA 7, 8
2. Reduce ICS dose by 25-50% every 3 months while maintaining control
3. Monitor closely for symptom recurrence

Special Considerations

Exercise-Induced Bronchoconstriction

• SABA 15-30 minutes before exercise
• For regular exercise, consider daily controller medications

Pregnancy

• Maintain optimal asthma control to ensure adequate fetal oxygenation
• Most asthma medications are considered safe during pregnancy

Follow-up and Monitoring

• Assess control at each visit
• Adjust therapy as needed based on symptom control
• Check inhaler technique regularly
• Provide written asthma action plan
• Schedule follow-up within 24-48 hours after emergency treatment

Common Pitfalls to Avoid

1. Using LABA monotherapy without ICS (increases risk of severe exacerbations)
2. Overreliance on rescue medications without addressing underlying inflammation
3. Failure to step up therapy when control is inadequate
4. Abrupt discontinuation of corticosteroids
5. Neglecting to check inhaler technique
6. Not providing a written asthma action plan

The evidence strongly supports that combination therapy with ICS/LABA provides superior asthma control compared to increasing ICS dose alone or adding leukotriene modifiers when stepping up from ICS monotherapy 1, 4, 9.