What is the preferred treatment for asthma?

Preferred Treatment for Asthma

The preferred treatment for asthma is inhaled corticosteroids (ICS) as the cornerstone of therapy, with treatment intensity adjusted according to asthma severity in a stepwise approach. 1

Classification and Treatment Algorithm

Treatment should be matched to the severity of asthma:

Mild Intermittent Asthma

• As-needed low-dose ICS-formoterol or low-dose ICS taken whenever SABA is used 1
• Alternative: Short-acting beta2-agonists (SABAs) alone as needed for symptom relief 2

Mild Persistent Asthma (Step 2)

• Daily low-dose inhaled corticosteroids as preferred controller treatment 2, 1
• Alternative options (less preferred):
  • Leukotriene receptor antagonists (e.g., montelukast) 2, 3
  • Cromoglycate or nedocromil 2

Moderate Persistent Asthma (Step 3-4)

• Low-dose inhaled corticosteroids plus long-acting beta2-agonists (LABAs) as preferred controller treatment 2, 1
• Alternative: Medium-dose inhaled corticosteroids 2

Severe Persistent Asthma (Step 5)

• High-dose inhaled corticosteroids plus long-acting beta2-agonists 2, 1
• May require addition of oral corticosteroids for control 2
• Consider referral to asthma specialist for add-on therapies 1

Key Medications and Their Roles

Inhaled Corticosteroids (ICS)

• Primary anti-inflammatory controller medication for persistent asthma of all severities 1
• Reduces airway inflammation, prevents exacerbations, and improves lung function 1
• Common options include fluticasone propionate, beclomethasone, budesonide, and mometasone 1
• Should be used regularly for optimal benefit 2

Beta-Agonists

• Short-acting beta2-agonists (SABAs): First-line treatment for acute symptom relief 2, 1

  • Use more than twice weekly indicates inadequate control and need to intensify therapy 2
  • New evidence supports combining with ICS in a single inhaler for as-needed use in mild asthma 4, 5

• Long-acting beta2-agonists (LABAs): For add-on therapy with ICS in moderate-severe asthma 2, 6

  • Should never be used as monotherapy due to increased risk of asthma-related death 2, 1, 6
  • Preferred adjunctive therapy to ICS for patients 12 years and older 2

Combination Therapy

• ICS/LABA combinations: More effective than increasing ICS dose alone in moderate-severe asthma 2, 6
• ICS/SABA combinations: Emerging evidence supports use as anti-inflammatory reliever therapy 7, 5
  • Albuterol-budesonide fixed-dose combination showed 26% lower risk of severe exacerbations compared to albuterol alone 5

Other Controller Options

• Leukotriene receptor antagonists: Alternative but less effective than ICS; may be used when ICS cannot be used 2, 1, 3
• Anticholinergics (e.g., ipratropium): Can provide additive benefit to SABAs in moderate-severe exacerbations 2, 1
• Magnesium sulfate: Consider IV administration in severe refractory exacerbations 2

Acute Exacerbation Management

• Oxygen therapy for hypoxemic patients 2, 1
• Short-acting beta-agonists via nebulizer or metered-dose inhaler with spacer 2
• Systemic corticosteroids for moderate-severe exacerbations 2
  • Typically 40-60 mg prednisone daily for 5-10 days in adults 2
• Consider adding ipratropium bromide to SABA for severe exacerbations 2, 1

Important Considerations and Pitfalls

Common Pitfalls

• Overreliance on SABAs without controller medication leads to worse outcomes 7
• Poor adherence to ICS therapy limits effectiveness and increases exacerbation risk 8, 4
• Failure to step up therapy when control is inadequate 2, 1
• Improper inhaler technique reduces medication delivery 1

Special Considerations

• Smoking reduces responsiveness to corticosteroids 2
• Pregnancy: Continue controller medications as benefits outweigh risks 1
• Exercise-induced bronchoconstriction: Pre-treatment with SABA 15-30 minutes before exercise 1

Monitoring and Follow-up

• Assess control using symptoms, exacerbation frequency, and lung function 1
• Consider stepping down therapy after 3 months of good control 1
• Monitor for potential steroid side effects with long-term ICS use 1
• Create written asthma action plan for all patients 1

The evidence strongly supports inhaled corticosteroids as the foundation of asthma management, with treatment intensity adjusted according to disease severity and control. Recent evidence also supports the use of combination ICS/bronchodilator inhalers as both maintenance and reliever therapy to improve adherence and outcomes.