What is the recommended treatment for managing asthma?

Recommended Treatment for Managing Asthma

The recommended treatment for asthma follows a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy for all patients with persistent asthma, even those with mild disease, according to the Global Initiative for Asthma (GINA) guidelines. 1

Diagnosis and Assessment

• Confirm diagnosis using:
  • Spirometry (FEV1) - gold standard
  • Peak expiratory flow (PEF) measurements
  • Assessment of symptoms and response to treatment
• Assess severity based on:
  • Symptom frequency and intensity
  • Use of short-acting beta-agonists (SABAs)
  • Activity limitations
  • Pulmonary function
  • Exacerbation history

Treatment Algorithm

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonists (SABAs) as needed
• Consider low-dose ICS even for mild disease 1

Step 2: Mild Persistent Asthma

• Low-dose ICS as daily controller medication
• SABAs as needed for symptom relief

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta-agonist (LABA) combination
  • Fluticasone propionate/salmeterol combination has shown superior efficacy compared to doubling the dose of fluticasone alone 2
• Alternative: Medium-dose ICS

Step 4: Severe Persistent Asthma

• Medium to high-dose ICS plus LABA
• Consider add-on therapy (leukotriene modifiers, tiotropium)

Step 5: Very Severe Persistent Asthma

• High-dose ICS plus LABA
• Consider add-on biologics for specific phenotypes
• Consider oral corticosteroids

Medication Dosing

• Short-acting beta-agonists (rescue medication):

  • Salbutamol/Albuterol: 5-10 mg nebulized every 15-30 minutes as needed during exacerbations 1

• Inhaled Corticosteroids (controller medication):

  • Standard daily dose of ICS (200-250 μg of fluticasone propionate or equivalent) achieves 80-90% of maximum therapeutic benefit 1
  • Higher doses provide minimal additional benefit but increase risk of side effects 3

• Combination Therapy:

  • Fluticasone propionate/salmeterol (Wixela Inhub®) available in three strengths:
    • 100/50 mcg, 250/50 mcg, or 500/50 mcg twice daily 4
    • Starting dosage based on asthma severity 4

Management of Acute Exacerbations

1. Immediate treatment:

   • High-flow oxygen via face mask
   • Nebulized salbutamol 5 mg or terbutaline 10 mg (half doses in very young children)
   • Add ipratropium 100 mg nebulized 6 hourly
   • Systemic corticosteroids (prednisolone 30-60 mg daily) 5, 1

2. For life-threatening features:

   • Consider intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion 5

3. Monitoring response:

   • Repeat PEF measurement after starting treatment
   • Maintain SaO2 >92%
   • Chart PEF before and after bronchodilator use 5

Step-Down Therapy

Once asthma control is achieved and maintained for at least 3 months:

• Consider stepping down therapy gradually
• Reducing ICS dose while maintaining LABA is more effective than removing LABA 6
• Monitor closely during step-down process

Patient Education and Follow-up

• Provide written asthma action plan
• Check and record inhaler technique
• Ensure PEF >75% of predicted or best and PEF diurnal variability <25% before discharge 5, 1
• Schedule primary care follow-up within 1 week and specialist follow-up within 4 weeks 1

Important Considerations

• Avoid common pitfalls:

  • Underuse of corticosteroids
  • Failure to appreciate severity
  • Inadequate objective measurement of airflow obstruction 5

• Special populations:

  • Children under 5: Clinical assessment more important than PEF
  • Pregnant women: Maintain optimal disease control for fetal oxygenation
  • Patients with comorbidities: Higher risk of mortality, may require more intensive monitoring 1

• Potential side effects of ICS:

  • Oral candidiasis (advise rinsing mouth after inhalation)
  • With long-term use: potential for glaucoma, cataracts, decreased bone mineral density 1, 4

The evidence clearly demonstrates that ICS therapy is the most effective anti-inflammatory treatment for asthma, with combination ICS/LABA therapy providing superior control for moderate to severe persistent asthma compared to increasing ICS dose alone 7.