What is the current treatment for asthma?

Current Treatment of Asthma

The current treatment of asthma follows a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma, with add-on therapies including long-acting beta-agonists (LABAs) for moderate to severe cases, and short-acting beta-agonists (SABAs) for rescue therapy. 1

Classification and Assessment

Asthma treatment is based on severity classification:

• Mild Intermittent: No daily controller medication needed; SABA as needed for symptoms
• Mild Persistent: Daily low-dose ICS (preferred) or alternatives like leukotriene receptor antagonists (LTRAs)
• Moderate Persistent: Daily low to medium-dose ICS plus LABA (preferred) or medium-dose ICS alone
• Severe Persistent: Daily high-dose ICS plus LABA, with possible addition of oral corticosteroids 1

Regular assessment of control is essential, with step-up in therapy if symptoms persist or step-down if well-controlled for at least 3 consecutive months. Increasing use of SABA more than twice weekly for symptom relief indicates inadequate control. 1

Controller Medications

Inhaled Corticosteroids (First-Line)

ICS are the most potent and consistently effective long-term control medications for asthma 1:

• Reduce airway inflammation
• Improve symptom scores
• Lower exacerbation rates
• Reduce need for rescue medications
• Decrease hospitalizations

Common ICS options include:

• Fluticasone propionate (88-264 mcg daily for low dose)
• Beclomethasone HFA (80-240 mcg daily for low dose)
• Budesonide DPI (180-600 mcg daily for low dose)
• Mometasone DPI (200 mcg daily for low dose) 2

Add-on Therapies

For patients whose asthma is not adequately controlled on ICS alone:

1. Long-acting beta-agonists (LABAs):

   • Preferred add-on therapy for patients ≥12 years with moderate to severe persistent asthma 1
   • Must be used in combination with ICS, never as monotherapy 1
   • Combination ICS/LABA inhalers improve compliance and outcomes 3, 4

2. Leukotriene Receptor Antagonists (LTRAs):

   • Alternative (not preferred) option for mild persistent asthma
   • Can be used as adjunctive therapy with ICS
   • Less effective than ICS/LABA combinations in patients ≥12 years 1
   • May be particularly useful for patients with allergic rhinitis or exercise-induced asthma 2

3. Other options:

   • Theophylline (less commonly used due to narrow therapeutic window)
   • Cromolyn sodium (alternative for mild persistent asthma) 5
   • Biologics (e.g., mepolizumab) for severe eosinophilic asthma 6

Quick-Relief Medications

• Short-acting beta-agonists (SABAs):

  • Used as needed for acute symptom relief
  • Increasing use (more than twice weekly) indicates poor control and need to step up controller therapy 1
  • Can be used 15-30 minutes before exercise to prevent exercise-induced bronchoconstriction 2

• Systemic corticosteroids:

  • For moderate to severe exacerbations
  • Typically 40-60 mg prednisone daily for 5-10 days in adults 2

Newer Approaches

Recent evidence supports the use of as-needed combination ICS/formoterol (a fast-acting LABA) as an alternative to regular ICS plus as-needed SABA in mild asthma:

• May reduce exacerbations and emergency department visits compared to SABA alone
• Similar efficacy to regular ICS with lower overall steroid exposure 7

Patient Education and Monitoring

• A written asthma action plan should be developed for all patients 1
• Regular follow-up is essential to assess response to therapy (2-6 weeks after treatment changes) 2
• Monitor for proper inhaler technique (spacers can increase lung deposition significantly) 2
• Consider referral to an asthma specialist for patients with:
  • Symptoms uncontrolled despite Step 3 therapy
  • ≥2 exacerbations requiring oral corticosteroids in the past year
  • Need for Step 4 care or higher 2

Common Pitfalls to Avoid

• Using LABA monotherapy without ICS (increases risk of severe exacerbations)
• Failing to recognize nighttime symptoms as a sign of poor control
• Inadequate monitoring of SABA use (using more than twice weekly indicates need for controller therapy)
• Not providing a written asthma action plan
• Poor inhaler technique leading to suboptimal medication delivery

By following this stepwise approach and regularly assessing control, most patients with asthma can achieve good symptom control and minimize exacerbations.