What is the step-by-step approach to asthma medication, including doses?

Step-by-Step Approach to Asthma Medication and Dosing

The stepwise approach is the cornerstone of asthma medication management, with inhaled corticosteroids (ICS) being the most effective controller medication for persistent asthma at all steps of care. 1 Treatment should be adjusted based on the level of asthma control, with step-up or step-down therapy as needed.

Classification of Asthma Severity

Before initiating therapy, assess asthma severity:

• Intermittent: Symptoms <2 days/week, nighttime awakenings <2x/month
• Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month
• Moderate Persistent: Daily symptoms, nighttime awakenings >1x/week but not nightly
• Severe Persistent: Throughout-the-day symptoms, often 2x/week nighttime awakenings 2

Step-by-Step Treatment Approach

Step 1: Intermittent Asthma

• Medication: Short-acting beta2-agonist (SABA) as needed
• Dose: Albuterol 2 puffs every 4-6 hours as needed
• Note: If using SABA more than twice weekly, consider step-up therapy 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose ICS
  • Examples and Doses:
    • Fluticasone HFA 88-264 mcg/day (adults)
    • Budesonide DPI 180-600 mcg/day
    • Beclomethasone HFA 80-240 mcg/day 2
• Alternatives: Leukotriene modifier, cromolyn, nedocromil, or theophylline

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS plus LABA OR medium-dose ICS
  • ICS/LABA Combination:
    • Fluticasone/salmeterol 100/50 mcg or 250/50 mcg, 1 inhalation twice daily 3
    • Budesonide/formoterol, 1 inhalation twice daily
  • Medium-dose ICS Examples:
    • Fluticasone HFA >264-440 mcg/day
    • Budesonide DPI >600-1200 mcg/day 2
• Alternative: Low-dose ICS plus leukotriene modifier or theophylline

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred: Medium-dose ICS plus LABA
  • Doses:
    • Fluticasone/salmeterol 250/50 mcg, 1 inhalation twice daily 3
    • Medium-dose ICS (see Step 3 doses) plus LABA
• Alternative: Medium-dose ICS plus either leukotriene modifier or theophylline

Step 5: Severe Persistent Asthma

• Preferred: High-dose ICS plus LABA
  • High-dose ICS Examples:
    • Fluticasone HFA >440 mcg/day
    • Budesonide DPI >1200 mcg/day 2
• Consider: Adding omalizumab for patients ≥12 years with allergies

Step 6: Severe Persistent Asthma (Uncontrolled)

• Preferred: High-dose ICS plus LABA plus oral corticosteroid
  • Oral Corticosteroid: Prednisolone 30-60 mg daily 2
• Consider: Adding omalizumab for patients ≥12 years with allergies

Adjusting Therapy Based on Control

Assess control at 2-6 week intervals initially, then every 1-6 months:

• Well-controlled: Consider step-down if maintained for at least 3 months
• Not well-controlled: Step up one level, check adherence and technique
• Very poorly controlled: Step up 1-2 levels, consider short course of oral corticosteroids 2

Acute Exacerbation Management

For severe exacerbations:

1. SABA: High-dose beta-agonist (salbutamol 5 mg or terbutaline 10 mg) via nebulizer or multiple actuations of MDI with spacer
2. Systemic steroids: Prednisolone 30-60 mg or IV hydrocortisone 200 mg immediately
3. For life-threatening features:
   • Add ipratropium (0.5 mg) nebulized
   • Consider IV aminophylline (250 mg over 20 minutes) or salbutamol/terbutaline (250 μg over 10 minutes) 2

Important Considerations

• Spacer Use: Always use spacers with non-breath-activated MDIs to reduce local side effects
• Mouth Rinsing: Advise patients to rinse mouth after ICS inhalation to reduce risk of oral candidiasis
• Lowest Effective Dose: Use the lowest dose of ICS that maintains asthma control
• Combination Therapy: Consider adding LABA rather than increasing ICS dose when control is inadequate 2

Common Pitfalls to Avoid

• Overreliance on SABAs: Using more than one canister per month indicates need for increased controller therapy
• Underuse of ICS: Many patients underuse controllers and overuse rescue medications
• Poor Inhaler Technique: Regularly assess and demonstrate proper technique
• Missing Written Action Plan: All patients should have a written plan for managing exacerbations
• Ignoring Comorbidities: Conditions like allergic rhinitis, sinusitis, and GERD can worsen asthma control 1

Growth Considerations in Children

• Low-to-medium dose ICS may be associated with approximately 1 cm reduction in growth velocity
• Benefits of ICS generally outweigh potential growth effects
• Use lowest effective dose and monitor growth in children 2

By following this stepwise approach and regularly assessing asthma control, most patients can achieve good symptom control and minimize the risk of exacerbations.