What are the guidelines for treating asthma?

Guidelines for Treating Asthma

The cornerstone of asthma management is a stepwise approach using inhaled corticosteroids (ICS) as first-line therapy for persistent asthma, with the addition of long-acting beta-agonists (LABAs) for moderate to severe cases, and as-needed short-acting beta-agonists (SABAs) for symptom relief. 1

Classification of Asthma Control

Asthma control should be classified into three categories:

• Controlled: Minimal daytime symptoms, no activity limitations, no nighttime symptoms, minimal reliever use, normal lung function, no exacerbations
• Partly Controlled: Some limitations in these areas
• Uncontrolled: Significant symptoms and limitations 1

Treatment Approach by Severity

Mild Asthma

• Preferred: Low-dose ICS-formoterol as needed
• Alternative: Daily low-dose ICS plus as-needed SABA 1

Moderate Asthma

• Preferred: Low-dose ICS-formoterol as maintenance and reliever
• Alternative: Medium-dose ICS plus as-needed SABA 1

Severe Asthma

• Primary: High-dose ICS plus LABA
• Consider: Adding biologics like omalizumab for allergic asthma 1

Medication Administration

Adults and Adolescents (≥12 years)

• Start with appropriate ICS dose based on asthma severity:
  • Mild: Wixela Inhub® 100/50 (fluticasone/salmeterol) 1 inhalation twice daily
  • Moderate: Wixela Inhub® 250/50 1 inhalation twice daily
  • Severe: Wixela Inhub® 500/50 1 inhalation twice daily 2

Children (4-11 years)

• Wixela Inhub® 100/50 1 inhalation twice daily 2
• For younger children (0-2 years), treatment is more challenging due to:
  • Variable bronchodilator response in the first year of life
  • Diagnosis relying almost entirely on symptoms
  • Limited controlled trials 3

Acute Exacerbation Management

Initial Treatment

• Nebulized salbutamol 5 mg or terbutaline 10 mg
• Oxygen 40-60% if available
• Prednisolone 30-60 mg orally or IV hydrocortisone 200 mg 1

Alternative if Nebulizer Unavailable

• 2 puffs of β-agonist via large volume spacer, repeated 10-20 times
• For MDI: 100 mcg per actuation, repeat up to 20 times with spacer 1

Monitoring Response

• Reassess after 15-30 minutes
• If PEF 50-75% predicted/best: Give prednisolone 30-60 mg
• If PEF >75% predicted/best: Step up usual treatment
• If PEF <33% or persistent severe symptoms: Consider hospital admission 1

Self-Management Plans

Self-management plans should include:

1. Monitoring of symptoms, peak flow, and medication use
2. Taking prearranged action according to written guidance
3. Key actions include:
   • Initiating or increasing inhaled steroid dose
   • Self-administering steroid tablets when peak flow falls below agreed level or <60% of normal
   • Urgently seeking medical attention when treatment is not working 3

Hospital Admission Criteria

Consider hospital admission if:

• Life-threatening features present
• Features of acute severe asthma persist after initial treatment
• PEF <33% of predicted/best after treatment
• Attack occurs in afternoon/evening
• Recent nocturnal symptoms
• History of recent hospital admission or previous severe attacks 1

Discharge Criteria

Patients should only be discharged when:

• They've been on discharge medication for 24 hours
• Inhaler technique has been checked and recorded
• PEF is >75% of predicted/best with diurnal variability <25%
• Treatment includes steroid tablets and inhaled steroids
• Patient has their own PEF meter and self-management plan 1

Common Pitfalls to Avoid

1. Underestimating severity: Each emergency consultation should be regarded as potentially acute severe asthma until proven otherwise
2. Delaying corticosteroid administration: Corticosteroids should be given early as benefits may take 6-12 hours
3. Inappropriate discharge: Ensure all discharge criteria are met before allowing patients to leave 1
4. Overreliance on SABAs alone: The dose-response curve to inhaled corticosteroids is relatively flat, and there is increasing evidence that addition of another class of therapy may be preferable to increasing the dose of inhaled corticosteroids in moderate-to-severe asthma 4
5. Poor adherence monitoring: Patient adherence to ICS-containing medications as daily maintenance therapy is often poor, leading to increased risk of severe exacerbations 5

Special Considerations

Pregnancy

• Women with worsening asthma during pregnancy require special attention 3

Children

• Symptoms develop in 50% of children with asthma by age 3 and in 80% by age 5
• Prednisolone dosing: 1-2mg/kg for 1-5 days
• Age-appropriate inhaler devices are essential 1

Growth Concerns with ICS

• Asthma itself can delay growth and puberty, though catch-up growth typically occurs
• Short-term reductions in tibial growth rate have been observed with ICS doses >400 µg/day, but these cannot be extrapolated to long-term effects
• Use the lowest effective dose that provides acceptable symptom control 3