Step Guide for Asthma Control in a 15-Year-Old Male
For a 15-year-old male with asthma, treatment should follow the stepwise approach outlined in the 2020 National Asthma Education and Prevention Program guidelines, starting with assessment of control and stepping up or down therapy as needed. 1
Initial Assessment and Classification
- Classify asthma severity based on symptoms, nighttime awakenings, rescue medication use, activity limitation, and lung function 2
- Assess both current impairment (day-to-day symptoms) and future risk (exacerbations) 2
- For adolescents aged 12 years and older, use the stepwise approach specific to this age group 1
Stepwise Treatment Approach for Ages 12 and Older
Step 1 (Intermittent Asthma)
- Preferred: As-needed short-acting beta-agonist (SABA) 1
- Alternative: As-needed inhaled corticosteroid (ICS) with SABA taken concomitantly 1
Step 2 (Mild Persistent Asthma)
- Preferred: Daily low-dose ICS plus as-needed SABA 1
- Alternative: Daily leukotriene receptor antagonist (LTRA), cromolyn, nedocromil, or theophylline with as-needed SABA 1
- Alternative: As-needed ICS and SABA used concomitantly 1
Step 3 (Moderate Persistent Asthma)
- Preferred: Low-dose ICS-formoterol in a single inhaler used as both daily controller and reliever therapy 1
- Alternative: Low-dose ICS plus long-acting beta-agonist (LABA) as daily controller with SABA as reliever 1
- Alternative: Medium-dose ICS plus as-needed SABA 1
Step 4 (Moderate-to-Severe Persistent Asthma)
- Preferred: Medium-dose ICS-formoterol in a single inhaler used as both daily controller and reliever therapy 1
- Alternative: Medium-dose ICS plus LABA with SABA as reliever 1
Step 5 (Severe Persistent Asthma)
- Preferred: High-dose ICS-LABA plus as-needed SABA 1
- Alternative: Consider adding long-acting muscarinic antagonist (LAMA) to ICS-LABA 1
- Alternative: Consider omalizumab for patients with allergies 1
Step 6 (Severe Persistent Asthma)
- Preferred: High-dose ICS-LABA plus oral systemic corticosteroid plus as-needed SABA 1
- Alternative: Consider omalizumab for patients with allergies 1
Important Considerations
Assessing Control and Adjusting Therapy
- Check adherence, inhaler technique, environmental factors, and comorbid conditions before stepping up therapy 1
- Reassess in 2-6 weeks after stepping up therapy 1
- Step down if asthma is well controlled for at least 3 consecutive months 1
- Consider consultation with asthma specialist if Step 4 or higher is required 1
Monitoring Parameters
- Symptoms (≤2 days/week indicates good control) 1
- Nighttime awakenings (≤2 times/month indicates good control) 1
- SABA use (≤2 days/week indicates good control) 1
- FEV1 or peak flow (>80% of predicted/personal best indicates good control) 1
Special Considerations for Adolescents
- For ICS-formoterol as both maintenance and reliever therapy (SMART approach), formoterol is the preferred LABA due to its rapid onset of action 1
- Studies show that in patients aged 12 years and older with moderate to severe persistent asthma, ICS-formoterol as both daily controller and reliever therapy is superior to higher-dose ICS as daily controller with SABA for quick relief 1
Environmental Control
- For patients with allergic asthma, consider subcutaneous allergen immunotherapy 1
- For patients with sensitization to dust mites, recommend impermeable pillow/mattress covers only as part of a multicomponent allergen mitigation intervention 1
- For patients with sensitization to pests, recommend integrated pest management 1
Medication Considerations
Inhaled Corticosteroids (ICS)
- First-line controller medication for persistent asthma 2
- At low doses, ICS therapy is generally considered safe with benefits outweighing risks 1
- Higher doses provide minimal additional benefit but increase risk of systemic effects 1
Long-Acting Beta-Agonists (LABAs)
- Should never be used as monotherapy due to increased risk of severe exacerbations 1, 2
- Always use in combination with ICS 1
- Combination of ICS and LABA addresses complementary aspects of asthma pathophysiology 3
Leukotriene Modifiers
- Alternative controller medication for mild persistent asthma 1
- Montelukast (Singulair) works by blocking leukotrienes 4
- FDA issued a Boxed Warning for montelukast in March 2020 regarding neuropsychiatric events 1
Quick-Relief Medications
- Use SABA as needed for symptoms 1
- Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed 1
- Increasing use of SABA or use >2 days/week for symptom relief generally indicates inadequate control and may require stepping up treatment 1
Common Pitfalls to Avoid
- Not stepping up therapy when asthma is poorly controlled 1
- Using LABA as monotherapy (increases risk of severe exacerbations) 1
- Overreliance on SABA without addressing underlying inflammation 1
- Not checking inhaler technique before changing therapy 1
- Not considering environmental triggers and allergen exposure 1
- Not stepping down therapy when asthma is well controlled for extended periods 1