What are the steps for treating asthma?

Asthma Treatment Steps

The stepwise approach to asthma treatment is based on assessing asthma control and adjusting therapy accordingly, with treatment steps ranging from Step 1 (for intermittent asthma) to Step 6 (for severe persistent asthma). 1

Assessment of Asthma Control

Before initiating or adjusting therapy, assessment of asthma control is essential:

• Determine whether asthma is "well controlled" or "not well controlled" based on symptoms, nighttime awakenings, interference with activities, rescue medication use, and lung function 1
• Evaluate both domains of asthma control:
  • Impairment: frequency of symptoms, need for rescue medications, effect on daily activities 1
  • Risk: frequency of exacerbations, decline in lung function, medication side effects 1

Stepwise Treatment Approach

Step 1 (Intermittent Asthma)

• Short-acting β-agonist (SABA) as needed for symptom relief 1
• No daily controller medication required 1

Step 2 (Mild Persistent Asthma)

• Preferred: Low-dose inhaled corticosteroids (ICS) daily 1
• Alternative options: Leukotriene modifiers, theophylline, cromolyn, or nedocromil 1

Step 3 (Moderate Persistent Asthma)

• Preferred: Low-dose ICS plus long-acting β-agonist (LABA) OR medium-dose ICS 1
• Alternative: Low-to-medium dose ICS plus either leukotriene modifier or theophylline 1

Step 4 (Moderate-to-Severe Persistent Asthma)

• Medium-dose ICS plus LABA 1
• Consider consultation with asthma specialist 1

Step 5 (Severe Persistent Asthma)

• High-dose ICS plus LABA 1
• Consider omalizumab for patients with allergies 1

Step 6 (Very Severe Persistent Asthma)

• High-dose ICS plus LABA plus oral corticosteroids 1
• Consider omalizumab for patients with allergies 1

Adjusting Treatment

• Step up if needed (first check inhaler technique, adherence, environmental triggers, and comorbid conditions) 1
• Step down if asthma is well controlled for at least 3 months 1
• Schedule follow-up visits:
  • Every 2-6 weeks when initiating therapy or stepping up treatment 1
  • Every 1-6 months after control is achieved 1
  • Every 3 months if step-down is anticipated 1

Important Safety Considerations

• LABAs should never be used as monotherapy for asthma - always combine with ICS 1, 2
• Monitor for adverse effects:
  • Local effects of ICS: oral candidiasis, dysphonia (advise rinsing mouth after use) 2
  • Systemic effects with high-dose ICS: adrenal suppression, decreased bone mineral density, growth effects in children 2
• Assess technique with all inhaled medications at every visit 1

Special Considerations

• Different age groups (0-4 years, 5-11 years, 12+ years) have specific treatment recommendations 1
• Exacerbations may occur even in patients with mild asthma, requiring vigilance and appropriate action plans 3
• Perform spirometry at initial assessment, after treatment stabilization, during periods of worsening symptoms, and at least every 1-2 years 1

Common Pitfalls to Avoid

• Underestimating severity: Even mild asthma can lead to severe exacerbations (0.12-0.77 per patient-year) 3
• Overreliance on SABAs: Frequent use (>2 days/week) indicates poor control and need for controller therapy 1
• Inadequate anti-inflammatory treatment: Focus should be on controlling underlying inflammation, not just symptoms 4
• Failure to step down therapy when appropriate: Reassess regularly to minimize medication exposure while maintaining control 1