What is the first line treatment for asthma?

First-Line Treatment for Asthma

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent asthma due to their superior effectiveness in improving asthma control compared to any other single long-term control medication. 1

Treatment Algorithm Based on Asthma Severity

Intermittent Asthma (Step 1)

• PRN short-acting beta-agonists (SABA) as needed for symptom relief 1

Persistent Asthma (Step 2 and above)

• Daily low-dose ICS is the preferred first-line controller treatment 1
• Alternative options (less preferred):
  • Leukotriene receptor antagonists (LTRA) - may be considered as a second-line option for mild persistent asthma with good compliance rates 1
  • Cromolyn, nedocromil, zileuton, or theophylline (with PRN SABA) 1

Stepwise Approach for Inadequate Control

If asthma symptoms remain uncontrolled on low-dose ICS:

• Step 3: Add long-acting beta-agonist (LABA) to low-dose ICS or increase to medium-dose ICS 1

  • For patients ≥12 years old, adding LABA to ICS is preferred over increasing ICS dose alone 1
  • Daily and PRN low-dose ICS-formoterol combination can be considered 1

• Step 4: Medium-dose ICS-LABA combination or add long-acting muscarinic antagonist (LAMA) 1

• Step 5-6: High-dose ICS-LABA combinations with consideration of biologics for severe asthma 1

Monitoring Asthma Control

• Increasing use of SABA more than twice weekly or more than two nights monthly indicates inadequate control and need to initiate or intensify anti-inflammatory therapy 1
• Assess control at each visit using validated tools like Asthma Control Test 2

Important Considerations

• ICS consistently improve asthma symptoms more effectively than any other single long-term control medication when used regularly 1, 3
• LABA should never be used as monotherapy for asthma due to increased risk of exacerbations and mortality 1
• For moderate-to-severe asthma, the combination of ICS-LABA is more effective than increasing ICS dose alone 4
• Recent evidence supports the use of as-needed ICS-formoterol combinations in mild asthma, which can reduce exacerbations compared to SABA alone 5

Common Pitfalls to Avoid

• Never use LABA as monotherapy for asthma control due to increased risk of exacerbations and mortality 1
• Avoid delaying initiation of ICS therapy in persistent asthma, as early intervention improves outcomes 3
• Don't confuse intermittent with persistent asthma - patients using SABA more than twice weekly likely need controller therapy 1
• Starting with high-dose ICS provides no additional clinical benefit in most efficacy parameters compared to low or moderate doses but may increase risk of side effects 6

Special Situations

• For acute exacerbations: Oral systemic corticosteroids are recommended for moderate to severe asthma exacerbations 1
• For patients with allergic asthma: Consider subcutaneous immunotherapy as adjunctive treatment for those with controlled symptoms 1
• For severe uncontrolled asthma despite appropriate treatment: Consider specialty referral and evaluation for biologic therapy 2