What are the recommended treatments for asthma management?

Recommended Treatments for Asthma Management

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

Stepwise Approach to Asthma Management

Step 1: Mild Intermittent Asthma

• Preferred treatment: As-needed short-acting beta-agonist (SABA) such as salbutamol
• Alternative: Low-dose ICS-formoterol as needed 1

Step 2: Mild Persistent Asthma

• Preferred treatment: Daily low-dose inhaled corticosteroid (ICS) plus as-needed SABA
• Alternative: Leukotriene receptor antagonist or low-dose ICS-formoterol as needed 2, 1

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose ICS plus long-acting beta-agonist (LABA)
• Alternative: Medium-dose ICS or low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Medium-dose ICS plus LABA
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2

Step 5: Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA
• Consider: Adding omalizumab for patients with allergies 2

Step 6: Very Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA plus oral corticosteroid
• Consider: Adding omalizumab for patients with allergies 2

Specific Medication Recommendations

Inhaled Corticosteroids (ICS)

• First-line therapy for persistent asthma 3
• Suppress airway inflammation and inhibit almost every aspect of the inflammatory process 3
• Standard daily dose: 200-250 μg of fluticasone propionate or equivalent achieves 80-90% of maximum therapeutic benefit 4
• Available in low, medium, and high doses depending on asthma severity 2

Beta-Agonists

• Short-acting (SABA): Used for quick relief of symptoms

  • Salbutamol 5 mg or terbutaline 10 mg via nebulizer or multiple actuations of metered-dose inhaler with spacer 2
  • Use of SABA more than twice weekly indicates inadequate control 2

• Long-acting (LABA): Used in combination with ICS for maintenance therapy

  • Should never be used as monotherapy due to increased risk of serious asthma-related events 5
  • Adding salmeterol to low-dose ICS provides greater clinical benefit than increasing ICS dose 6

Combination Therapy

• ICS/LABA combinations (e.g., fluticasone/salmeterol) are indicated for twice-daily treatment of asthma in patients aged 4 years and older 5
• More effective than increasing ICS dose alone for moderate-to-severe asthma 3

Additional Controller Medications

• Leukotriene receptor antagonists: Alternative to ICS for mild asthma or add-on therapy
• Ipratropium bromide: Add 0.5 mg to nebulized beta-agonist for acute severe asthma 1
• Theophylline: Alternative add-on therapy with ICS, requires monitoring of serum levels 2
• Omalizumab: For severe allergic asthma, reduces need for oral and inhaled steroids 2

Management of Acute Severe Asthma

Initial Assessment and Treatment

1. High-dose inhaled beta-agonists: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen 2
2. Add ipratropium bromide 0.5 mg to nebulized beta-agonist 1
3. High-dose systemic steroids: Prednisolone 30-60 mg or IV hydrocortisone 200 mg 2

Monitoring and Ongoing Management

• Continue oxygen therapy with target saturation >94% 1
• Repeat nebulizations as needed based on response 1
• Monitor peak expiratory flow, oxygen saturation, respiratory rate, and heart rate 1

Common Pitfalls to Avoid

1. Underestimation of severity: Each emergency consultation should be regarded as potentially acute severe asthma until proven otherwise 1

2. Delayed corticosteroid administration: Benefits may not occur for 6-12 hours, so administer early 1

3. Inappropriate discharge: Patients should meet all discharge criteria before leaving hospital 1

4. Overreliance on SABA: Frequent use indicates poor control and need for controller medication 2

5. LABA monotherapy: Increases risk of serious asthma-related events 5

6. Inadequate step-up in therapy: Failure to increase treatment when control is inadequate 2

7. Failure to identify and address triggers: Including allergens, occupational sensitizers, or comorbidities 7

8. Inappropriate ICS dosing: Using excessively high doses when standard doses achieve 80-90% of maximum benefit 4

The evidence clearly demonstrates that a systematic stepwise approach to asthma management, with appropriate medication selection based on asthma severity and control, is most effective for reducing morbidity and mortality while improving quality of life.