What is the recommended treatment for asthma?

Treatment of Asthma

Inhaled corticosteroids (ICS) are the first-line controller medication for persistent asthma, with a stepwise approach recommended for managing symptoms and preventing exacerbations. 1

Controller Medications

First-Line Therapy

• Inhaled Corticosteroids (ICS): The foundation of asthma management for persistent asthma
  • Low-dose ICS options include:
    • Fluticasone propionate (88-264 mcg daily)
    • Beclomethasone HFA (80-240 mcg daily)
    • Budesonide DPI (180-600 mcg daily)
    • Mometasone DPI (200 mcg daily) 1

Step-Up Therapy

• For inadequate control on low-dose ICS:

  • Add a long-acting beta-agonist (LABA) to low-dose ICS (preferred option)
  • OR increase to medium-dose ICS 1

• ICS/LABA combination therapy:

  • Provides superior control compared to increasing ICS dose alone 2
  • Available as combination inhalers (e.g., fluticasone/salmeterol) 3
  • Important safety warning: LABAs should never be used as monotherapy due to increased risk of asthma-related death 1, 3

Alternative Controller Options

• Leukotriene Receptor Antagonists (LTRAs):

  • Second-line alternative for mild persistent asthma 4
  • Options include montelukast (Singulair) and zafirlukast (Accolate) 1, 5
  • Can be used as adjunctive therapy with ICS, though adding LABAs is preferred for patients 12 years and older 4

• Other alternatives:

  • Theophylline (requires serum concentration monitoring)
  • Cromolyn sodium and nedocromil (mast cell stabilizers) 1

Relief Medications

• Short-acting beta-agonists (SABAs):
  • Most effective therapy for rapid reversal of airflow obstruction
  • Used as needed for acute symptoms 4
  • Increasing use (>2 days/week or >2 nights/month) indicates inadequate control and need to initiate or intensify controller therapy 4

Management of Exacerbations

• For moderate to severe exacerbations:
  • Oral systemic corticosteroids (typically 40-60 mg prednisone daily for 5-10 days in adults) 1
  • High-dose nebulized beta-agonists 4
  • Consider adding ipratropium for severe exacerbations 1
  • Oxygen therapy for hypoxemic patients 1

Step-Down Therapy

• Once asthma is well-controlled for at least 3 months:
  • Reduce ICS dose by 25-50% 1
  • When stepping down from ICS/LABA combination, maintaining the LABA while reducing the ICS dose is more effective than eliminating the LABA 6
  • Schedule follow-up visits every 2-6 weeks during step-down to assess symptom control 1

Common Pitfalls and Caveats

1. Inappropriate use of LABAs:

   • Never use LABAs as monotherapy for asthma due to increased risk of asthma-related death 1, 3
   • Always combine with an appropriate dose of ICS

2. Overreliance on SABAs:

   • Increasing use of rescue medication indicates poor control and need to adjust controller therapy 4

3. Inadequate ICS dosing:

   • Most patients achieve 80-90% of maximum benefit with standard doses (200-250 μg fluticasone or equivalent) 7
   • Higher doses increase risk of side effects without proportional increase in benefit

4. Abrupt discontinuation of corticosteroids:

   • Never abruptly substitute LTRAs for corticosteroids 5
   • Taper patients slowly from systemic corticosteroids when transitioning to inhaled therapy 3

5. Failure to monitor for side effects:

   • Watch for oral candidiasis with ICS (advise rinsing mouth after use) 1
   • Monitor for potential steroid side effects including growth effects, increased blood pressure, osteoporosis, and cataracts 1

6. Neuropsychiatric events with montelukast:

   • Monitor for agitation, depression, sleep disturbances, and other neuropsychiatric symptoms 5

By following this stepwise approach to asthma management with appropriate medication selection and monitoring, most patients can achieve good symptom control and minimize exacerbations while reducing the risk of medication-related adverse effects.