When should asthma treatment be increased?

When to Increase Asthma Treatment

Asthma treatment should be increased when the short-acting inhaled β-agonist is being used more than two or three times daily or when symptom control is not good, defined as having minimal chronic symptoms, infrequent exacerbations, minimal need for relieving bronchodilators, and no limitations on activities. 1

Assessment of Asthma Control

Control should be evaluated using both impairment and risk domains:

Impairment Domain

• Symptoms occurring >2 days/week indicates not well-controlled asthma 1
• Nighttime awakenings 1-3 times/week suggests inadequate control 1
• Interference with normal activity indicates poor control 1
• Short-acting β2-agonist use >2 days/week for symptom control (not prevention of exercise-induced bronchospasm) signals the need for treatment adjustment 1
• FEV1 or peak flow 60-80% of predicted/personal best indicates not well-controlled asthma 1

Risk Domain

• ≥2 exacerbations requiring oral systemic corticosteroids per year indicates poor control and need for step-up therapy 1
• Progressive loss of lung function requires treatment intensification 1

Stepwise Approach to Treatment Escalation

Before increasing therapy:

• Check compliance with current medications 1
• Verify proper inhaler technique 1
• Assess for environmental triggers contributing to worsening symptoms 1

When to Step Up Treatment

1. For patients on intermittent short-acting β-agonist only (Step 1):

   • Step up to daily low-dose inhaled corticosteroids (ICS) when symptoms occur >2 days/week 1

2. For patients on low-dose ICS (Step 2):

   • Add a long-acting β-agonist (LABA) when asthma is not adequately controlled 1
   • Alternative: Increase ICS within medium-dose range 1

3. For patients on low-dose ICS plus LABA (Step 3):

   • Increase to medium-dose ICS plus LABA when control remains inadequate 1

4. For patients on medium-dose ICS plus LABA (Step 4):

   • Consider high-dose ICS plus LABA if symptoms persist 1
   • Add-on long-acting muscarinic antagonists are recommended for step 5 (moderate-severe persistent asthma) 2

5. For severe persistent asthma:

   • Consider oral corticosteroids when high-dose ICS plus LABA fails to achieve control 1

Special Considerations

Biomarker-Guided Treatment

• Consider using biomarkers of type-2 airway inflammation to guide treatment decisions, as this approach may reduce exacerbations more effectively than symptom-guided approaches 1
• Fractional exhaled nitric oxide testing can assist in monitoring response to therapy but should not be used alone 2

Exacerbations

• For worsening symptoms with day-by-day deterioration of peak flow to below 60% of patient's best, consider a short course of oral corticosteroids 1
• Prednisolone 30-40 mg daily should be given until lung function values return to previous best (typically 7-21 days) 1

Medication Adjustments

• For patients who don't respond to initial therapy after 2 weeks, replacing the current strength with a higher strength may provide additional improvement 3
• If a previously effective regimen fails to provide adequate control, reevaluate and consider additional therapeutic options 3
• A one to three month period of stability should be demonstrated before attempting to step down treatment 1

Common Pitfalls to Avoid

• Overtreatment: The stepwise approach may lead to inappropriately excessive doses of ICS, resulting in unnecessary systemic adverse effects 1
• Ignoring comorbidities: Persistent symptoms may be due to overlapping disorders or comorbidities rather than inadequate asthma treatment 1
• Focusing only on symptoms: Asthma control involves both symptom management and reducing future risk of exacerbations 1, 4
• Inadequate follow-up: Regular monitoring is essential as asthma often varies over time 1
• Using LABA monotherapy: LABAs should never be used without ICS due to increased risk of asthma-related death 1

Remember that treatment decisions should prioritize reducing morbidity, mortality, and improving quality of life through optimal asthma control.