What is the stepwise approach for managing asthma?

Stepwise Approach for Managing Asthma

The preferred treatment for asthma follows a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy, adjusting treatment based on symptom control and exacerbation risk assessment. 1

Classification of Asthma

Asthma should be classified into four categories to guide initial treatment:

• Intermittent: Symptoms <1x/week, nighttime symptoms <2x/month, normal lung function (FEV₁ >80%)
• Mild Persistent: Symptoms >1x/week but <daily, nighttime symptoms >2x/month, FEV₁ >80%
• Moderate Persistent: Daily symptoms, nighttime symptoms >1x/week, FEV₁ 60-80%
• Severe Persistent: Continuous symptoms, frequent nighttime symptoms, FEV₁ <60%

Assessment should evaluate both current impairment (symptoms, activity limitation, lung function) and future risk (exacerbations, medication side effects) 1, 2.

Stepwise Management Approach

Step 1 (Intermittent Asthma)

• Preferred: As-needed low-dose ICS-formoterol
• Alternative: As-needed SABA (not recommended as sole therapy) 1

Step 2 (Mild Persistent)

• Preferred: Daily low-dose ICS plus as-needed SABA, or as-needed ICS-formoterol
• Alternative: Leukotriene receptor antagonists (LTRAs), cromolyn, or theophylline 1

Step 3 (Moderate Persistent)

• Preferred: Low-dose ICS-LABA as maintenance 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 1

Step 4 (Moderate-to-Severe Persistent)

• Preferred: Medium-dose ICS-LABA plus as-needed SABA, or medium-dose ICS-formoterol as both maintenance and reliever
• Alternative: Medium-dose ICS plus LABA or LTRA 1

Step 5 (Severe Persistent)

• High-dose ICS-LABA plus as-needed SABA
• Consider add-on treatments:
  • Long-acting muscarinic antagonists (LAMA)
  • Biologics (omalizumab for allergic asthma)
  • Azithromycin (in selected patients)
  • Oral corticosteroids (lowest possible dose) 1, 3

Step 6 (Very Severe Persistent)

• High-dose ICS-LABA plus oral corticosteroids
• Consider biologics based on specific phenotype 2, 1

Age-Specific Considerations

Children 0-4 years

• Consider short course of ICS with SABA at respiratory illness onset 1

Children 5-11 years

• Follow similar stepwise approach with age-appropriate dosing
• SMART approach (ICS-formoterol as maintenance and reliever) is preferred for Steps 3-4 1

Monitoring and Adjusting Treatment

1. Assessment Frequency:

   • 2-6 weeks when initiating therapy
   • 1-6 months when control is achieved 1

2. Step Up if:

   • Symptoms persist
   • Exacerbations occur
   • Activity limitation continues
   • Lung function deteriorates 1

3. Step Down if:

   • Good control maintained for 3+ months
   • Reduce gradually to find minimum effective dose 1

Common Pitfalls to Avoid

1. Underestimating Severity: Many patients and physicians underestimate symptom severity or overestimate control level 2

2. SABA-Only Treatment: Never treat asthma with SABA alone due to increased exacerbation risk 1, 3

3. LABA Monotherapy: LABAs must never be used without ICS due to safety concerns 1

4. Overlooking Comorbidities: Conditions like GERD and allergies can complicate management 1

5. Inadequate Follow-up: Regular monitoring is essential for appropriate therapy adjustments 1, 4

6. Poor Adherence: Only about 66% of persistent asthmatics use their medication daily as prescribed 4

The stepwise approach to asthma management, when properly implemented, can help approximately 70% of patients achieve good asthma control across severity levels 1. Regular assessment of both symptom control and exacerbation risk is essential for optimizing treatment and improving patient outcomes.