What is the first line treatment for patients with asthma?

First Line Treatment for Patients with Asthma

The first line treatment for patients with asthma is an inhaled short-acting beta-agonist (SABA) as needed for symptom relief, with the addition of low-dose inhaled corticosteroids (ICS) for patients with persistent asthma. 1

Stepwise Approach to Asthma Management

Step 1: Mild Intermittent Asthma

• Preferred treatment: Inhaled short-acting beta-agonist as needed for symptom relief 1
• No daily controller medication is required at this step 1
• Patient education, environmental control, and management of comorbidities should be addressed at all steps 1

Step 2: Mild Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroid daily 1
• Alternative treatments: Leukotriene receptor antagonists (such as montelukast), cromolyn, or theophylline 1
• Leukotriene receptor antagonists are appropriate alternatives for patients unable or unwilling to use inhaled corticosteroids 1
• Inhaled corticosteroids are the most effective anti-inflammatory treatment available for asthma 2

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroid plus long-acting inhaled beta-agonist OR medium-dose inhaled corticosteroid 1
• Alternative treatment: Low-dose inhaled corticosteroid plus either leukotriene receptor antagonist, theophylline, or zileuton 1
• The combination of ICS plus LABA provides greater asthma control than increasing the ICS dose alone 3, 4

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Medium-dose inhaled corticosteroid plus long-acting inhaled beta-agonist 1
• Alternative treatment: Medium-dose inhaled corticosteroid plus either leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5 and 6: Severe Persistent Asthma

• Preferred treatment: High-dose inhaled corticosteroid plus long-acting inhaled beta-agonist, with consideration of omalizumab for patients with allergies 1
• Step 6 adds oral corticosteroids to the Step 5 regimen 1

Evidence Supporting Inhaled Corticosteroids as First-Line Controller Therapy

• Inhaled corticosteroids are the most consistently effective long-term controller medication at all steps of care for persistent asthma 1
• ICS improve asthma control more effectively in both children and adults than leukotriene receptor antagonists or any other single long-term controller medication 1
• ICS not only control asthma symptoms and improve lung function but also prevent exacerbations and may reduce asthma mortality 2
• The dose-response curve to inhaled corticosteroids is relatively flat, with 80-90% of maximum benefit achieved at standard doses (equivalent to 200-250 μg of fluticasone propionate) 5

Combination Therapy Considerations

• For patients with moderate-to-severe asthma not controlled on low-dose ICS, adding a long-acting beta-agonist (LABA) is more effective than doubling the ICS dose 4, 6
• LABAs should never be used as monotherapy for asthma control; they should always be used in combination with ICS 1, 7
• There have been safety concerns about LABAs, with an increase in severe exacerbations and deaths when added to usual asthma therapy without ICS 1

Important Clinical Considerations

• Assess asthma control regularly and adjust therapy accordingly 1
• Step up therapy if needed (first check adherence, environmental control, and comorbid conditions) 1
• Step down therapy if possible when asthma is well controlled for at least three months 1
• Use of inhaled short-acting beta-agonist more than twice weekly for symptom relief generally indicates inadequate control and the need to step up treatment 1
• Written action plans detailing medications and environmental control strategies should be provided to all patients with asthma 1

Monitoring and Follow-up

• Regular monitoring of lung function with spirometry or peak flow is essential for assessing asthma control 1
• Planned asthma care visits are essential for adequate teaching and asthma control 1
• Patients with intermittent asthma may need evaluation only once yearly, while those on controller agents should be seen at least twice yearly 1