What is the first line treatment for asthma?

First-Line Treatment for Asthma

Inhaled corticosteroids (ICS) are the first-line controller medication for persistent asthma, as they are the most effective treatment for controlling asthma symptoms, improving lung function, and preventing exacerbations. 1

Treatment Algorithm Based on Asthma Severity

Initial Assessment and Classification

1. Determine asthma severity based on:
   • Symptom frequency (daytime and nighttime)
   • Rescue medication use
   • Lung function (if available)
   • Risk of exacerbations

Step-wise Treatment Approach

Step 1: Intermittent Asthma

• Primary treatment: As-needed short-acting beta-agonist (SABA)
• For symptoms occurring ≤2 days/week, no nighttime awakenings, normal lung function

Step 2: Mild Persistent Asthma

• Preferred treatment: Daily low-dose ICS plus as-needed SABA 2, 1
• Common 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)

Step 3: Moderate Persistent Asthma

• Preferred treatment: Daily and as-needed low-dose ICS-formoterol 2
• Alternative: Daily medium-dose ICS plus as-needed SABA

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Daily medium-dose ICS-LABA combination 2, 1
• The combination of ICS and LABA provides greater asthma control than increasing ICS dose alone 3

Step 5-6: Severe Persistent Asthma

• Preferred treatment: Daily medium-to-high dose ICS-LABA 2
• Consider adding biologics for appropriate patients

Key Considerations for ICS Therapy

Benefits of ICS as First-Line Therapy

• ICS are the only currently available asthma therapy that effectively suppress airway inflammation 4
• They control symptoms, improve lung function, prevent exacerbations, and may reduce asthma mortality 4
• More effective than leukotriene receptor antagonists in controlling asthma 1

Important Warnings and Precautions

• LABAs should never be used as monotherapy due to increased risk of asthma-related death 1, 5
• Monitor for potential side effects of ICS including oral candidiasis, dysphonia, and with long-term use: growth effects in children, glaucoma, and cataracts 1
• Advise patients to rinse their mouth with water (without swallowing) after ICS inhalation to reduce risk of oral candidiasis 5

Alternative Controller Medications

• Leukotriene receptor antagonists (LTRAs) are a second-line alternative for mild persistent asthma 1
• Cromolyn sodium and nedocromil are alternative options but less effective than ICS 1
• Theophylline is another alternative but requires serum concentration monitoring 1

Monitoring and Follow-up

• Assess asthma control at regular intervals (every 2-6 weeks initially, then every 1-6 months)
• Consider stepping down therapy after achieving well-controlled asthma for at least 3 months 1
• When stepping down, reducing ICS dose by 25-50% is preferable to discontinuing ICS completely 6
• Adding a LABA to low-dose ICS is more effective than switching to higher-dose ICS alone when stepping up therapy 7, 8

Common Pitfalls to Avoid

1. Using LABA monotherapy without ICS (increases risk of asthma-related death)
2. Relying solely on rescue medications without addressing underlying inflammation
3. Failing to step up therapy when asthma is not well-controlled
4. Not providing patients with a written asthma action plan
5. Inadequate follow-up to assess treatment response and adjust therapy as needed

By following this evidence-based approach to asthma management with ICS as first-line therapy, clinicians can help patients achieve optimal asthma control while minimizing the risk of exacerbations and long-term complications.