What is the first line treatment for bronchial asthma?

First-Line Treatment for Bronchial Asthma

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent bronchial asthma due to their superior effectiveness in controlling airway inflammation. 1

Treatment Algorithm for Bronchial Asthma

Initial Assessment and Classification

• Determine asthma severity based on symptom frequency, nighttime awakenings, and lung function 1
• Assess current level of symptom control and risk of future exacerbations 1
• Evaluate patient's ability to use inhaler devices correctly 1

First-Line Therapy

• Inhaled corticosteroids (ICS) are the foundation of persistent asthma treatment 1
• ICS improve asthma control more effectively than any other single long-term control medication 1
• ICS suppress airway inflammation, reduce airway hyperresponsiveness, and control asthma symptoms 2
• For mild persistent asthma, start with low-dose ICS twice daily 1

Rescue Medication

• Short-acting beta2-agonists (SABAs) such as albuterol are the treatment of choice for quick relief of acute symptoms 1
• Increasing use of SABA (more than 2 days per week) indicates inadequate asthma control and need to initiate or intensify anti-inflammatory therapy 1

Step-Up Therapy When Control Is Not Achieved

1. Increase ICS dose if symptoms are not controlled on standard doses 1
2. Add long-acting beta2-agonists (LABAs) in combination with ICS for patients ≥12 years old with moderate to severe persistent asthma 1
   • LABAs should never be used as monotherapy 1
   • Combination ICS/LABA is preferred over increasing ICS dose alone in patients ≥12 years 1
3. Consider leukotriene receptor antagonists (LTRAs) as alternative or adjunctive therapy 1
   • LTRAs are an alternative (though not preferred) option for mild persistent asthma 1
   • Can be added to ICS if control is inadequate, though LABAs are preferred as add-on therapy in patients ≥12 years 1

Special Considerations

• Proper inhaler technique is essential for medication effectiveness 1
• Spacer devices can increase the effectiveness of inhaled medications 1
• A 1-3 month period of stability should be demonstrated before considering step-down treatment 1
• For acute exacerbations, short courses of oral corticosteroids are often necessary 1

Monitoring and Follow-Up

• Regularly assess symptom control and medication adherence 1
• Consider increasing treatment if short-acting beta2-agonists are needed more than 2-3 times daily 1
• Check compliance before any treatment increase 1

Common Pitfalls to Avoid

• Using LABAs as monotherapy (increases risk of asthma exacerbations and death) 1
• Underestimating the importance of proper inhaler technique 1
• Failing to step up therapy when control is inadequate 1
• Not recognizing that increasing use of rescue medications indicates poor control 1

The evidence consistently supports inhaled corticosteroids as the cornerstone of asthma management, with additional therapies added in a stepwise approach when control is not achieved with ICS alone. This approach has been shown to effectively reduce symptoms, prevent exacerbations, and improve quality of life for patients with persistent asthma.