Treatment for Severe Asthma
The recommended treatment for severe asthma includes high-dose inhaled corticosteroids (ICS) combined with long-acting beta2-agonists (LABA), with the addition of oral systemic corticosteroids if control cannot be achieved with this combination. 1
First-Line Treatment for Severe Asthma
Step 4 Therapy (Severe Persistent Asthma)
- High-dose inhaled corticosteroids
- Long-acting inhaled beta2-agonists (LABA)
This combination forms the cornerstone of severe asthma management, targeting both the inflammatory and bronchoconstrictive components of the disease 1.
When to Add Systemic Corticosteroids
If control cannot be achieved with high-dose ICS and LABA:
- Add oral corticosteroid tablets or syrup (1-2 mg/kg/day, generally not exceeding 60 mg/day) 1
- Make repeated attempts to reduce systemic corticosteroids while maintaining control with high-dose inhaled corticosteroids 1
Medication Selection and Dosing
Inhaled Corticosteroids
High-dose ICS options include:
- Fluticasone DPI (approved for children 4 years and older)
- Budesonide nebulizer solution (approved for children 1-8 years of age) 1
Long-Acting Beta2-Agonists
- Salmeterol DPI (approved for children 4 years and older) 1
- Formoterol
Rescue Medications
For acute symptom relief:
- Salbutamol (albuterol): 5-10 mg nebulized every 15-30 minutes as needed
- Ipratropium bromide: 0.5 mg nebulized every 6 hours 2
Special Considerations
Age-Specific Recommendations
- Adults and adolescents (12+ years): High-dose ICS plus LABA is the preferred treatment 1
- Children (6-11 years): Combination therapy is based on extrapolation from studies in older children and adults 1
- Young children (<5 years): Limited data on LABA use; medium-dose ICS has demonstrated effectiveness 1
Severe Asthma with Eosinophilic Phenotype
For patients with severe asthma with an eosinophilic phenotype that remains uncontrolled despite high-dose ICS plus LABA:
- Consider adding mepolizumab (anti-IL5) as maintenance therapy 3
- Recommended dosage: 100 mg administered once every 4 weeks by subcutaneous injection for adults and adolescents aged 12 years and older 3
Monitoring and Follow-Up
Assessing Treatment Response
Monitor:
- Symptom control (frequency and intensity)
- Lung function (FEV1, PEF)
- Exacerbation frequency
- Medication side effects 1
Indicators of Poor Control
- Increasing use of short-acting beta agonists (more than twice weekly)
- Nighttime symptoms (more than twice monthly)
- Activity limitations due to asthma 1
Common Pitfalls to Avoid
Underuse of inhaled corticosteroids: ICS are the foundation of persistent asthma management 2
Using LABA alone: This increases the risk of asthma-related events including deaths. Always use LABA in combination with ICS 4
Failure to address comorbidities: Conditions like GERD, rhinosinusitis, obesity, and sleep apnea can worsen asthma control 2
Inadequate patient education: Provide a written asthma action plan that includes daily management instructions, recognition of worsening symptoms, response to worsening symptoms, and when to seek emergency care 2
Abrupt discontinuation of corticosteroids: Do not stop taking corticosteroid medications unless instructed by a healthcare provider 3
By following this stepwise approach to severe asthma management, focusing on high-dose ICS plus LABA as the foundation and adding systemic corticosteroids when necessary, patients can achieve better symptom control and reduced risk of exacerbations.