Stepwise Approach for Treating Asthma
The stepwise approach is the cornerstone of asthma management, with treatment progressively increased to achieve symptom control and reduce exacerbation risk, and stepped down after a period of sustained control. 1
Classification of Asthma Severity
Asthma severity is classified into four categories to guide initial treatment:
| Severity Classification | Symptoms | Nighttime Awakenings | SABA Use | Activity Limitation | Lung Function | Exacerbations |
|---|---|---|---|---|---|---|
| Intermittent | ≤2 days/week | ≤2 times/month | ≤2 days/week | None | Normal FEV1 (>80%) | 0-1/year |
| Mild Persistent | >2 days/week but not daily | 3-4 times/month | >2 days/week but not daily | Minor limitation | Normal FEV1 (>80%) | ≥2/year |
| Moderate Persistent | Daily | >1 time/week but not nightly | Daily | Some limitation | FEV1 60-80% | ≥2/year |
| Severe Persistent | Throughout the day | Often 7 times/week | Several times per day | Extreme limitation | FEV1 <60% | ≥2/year |
Stepwise Treatment Algorithm
Step 1: Intermittent Asthma
- Preferred: As-needed low-dose ICS-formoterol OR as-needed SABA
- Alternative: Consider daily low-dose ICS for patients with risk factors for exacerbations
Step 2: Mild Persistent Asthma
- Preferred: Daily low-dose ICS plus as-needed SABA OR as-needed ICS-formoterol
- Alternative: LTRA, cromolyn, nedocromil, or theophylline
Step 3: Moderate Persistent Asthma
- Preferred: Low-dose ICS-LABA plus as-needed SABA OR low-dose ICS-formoterol as both maintenance and reliever (SMART approach)
- Alternative: Medium-dose ICS plus as-needed SABA OR low-dose ICS plus LTRA
- Consider consultation with asthma specialist
Step 4: Moderate-to-Severe Persistent Asthma
- Preferred: Medium-dose ICS-LABA plus as-needed SABA OR medium-dose ICS-formoterol as both maintenance and reliever
- Alternative: Medium-dose ICS plus LTRA or theophylline
Step 5: Severe Persistent Asthma
- Preferred: High-dose ICS-LABA plus as-needed SABA
- Add-on options: Tiotropium, LTRA, theophylline
- Referral to asthma specialist required
Step 6: Very Severe Persistent Asthma
- Preferred: High-dose ICS-LABA plus oral corticosteroids plus as-needed SABA
- Add-on options: Biologics (omalizumab for allergic asthma, anti-IL-5 for eosinophilic asthma)
- Specialist care required
Principles for Adjusting Therapy
When to Step Up
- If asthma is not well-controlled after 2-6 weeks of current therapy
- Check inhaler technique, adherence, environmental control, and comorbidities first
- Step up 1-2 steps as needed based on severity of symptoms
- For acute exacerbations: Consider short course of oral corticosteroids
When to Step Down
- If asthma is well-controlled for at least 3 months
- Reduce treatment gradually to find minimum effective dose
- Maintain ICS therapy even when symptoms improve
- Step down cautiously, especially for patients with history of severe exacerbations
Important Considerations and Cautions
- LABAs must never be used as monotherapy and should always be combined with ICS 1
- Daily use of LABAs should not exceed 100 mcg salmeterol or 24 mcg formoterol 2
- Regular assessment of symptom control and exacerbation risk is necessary 1
- Consider subcutaneous allergen immunotherapy for allergic asthma 2
- SMART approach (ICS-formoterol as both maintenance and reliever) is preferred for patients ≥5 years old at steps 3 and 4 1
Common Pitfalls to Avoid
- Inadequate follow-up: Regular monitoring is essential to adjust therapy appropriately 1
- Overlooking comorbidities: Conditions like GERD, obstructive sleep apnea, and allergic bronchopulmonary aspergillosis can complicate asthma management 1
- Relying on single measures to assess control: Use multiple measures for comprehensive assessment 1
- Overreliance on SABA alone: SABA monotherapy is no longer recommended for any level of asthma 1, 3
- Failure to address poor adherence: Check inhaler technique and adherence before stepping up therapy 1
Monitoring and Assessment
- Assess asthma control at regular intervals (2-6 weeks when initiating therapy; 1-6 months when control is achieved)
- Evaluate both domains: current impairment (symptoms, activity limitation, SABA use) and future risk (exacerbations, medication side effects)
- Consider written asthma action plans to guide self-management
The stepwise approach to asthma management provides a structured framework for treatment decisions, but approximately 70% of patients can achieve good asthma control across severity strata with appropriate therapy and regular monitoring 1.