What medications should an asthmatic patient be on?

Medication Management for Asthma Patients

Asthma patients should be treated with inhaled corticosteroids (ICS) as first-line controller medication, with additional therapies added in a stepwise approach based on asthma severity to reduce morbidity and mortality. 1

Stepwise Approach to Asthma Medication Management

Mild Intermittent Asthma

• No daily controller medication needed 1
• Short-acting inhaled beta2-agonist (SABA) as needed for symptom relief 1
• Increased use of SABA (more than twice weekly) indicates need to step up therapy 1

Mild Persistent Asthma (Step 2)

• Low-dose inhaled corticosteroids as preferred daily controller medication 1
• Alternative options include leukotriene receptor antagonists, cromolyn, nedocromil, or sustained-release theophylline 1
• Leukotriene receptor antagonists are easier to use with higher compliance rates but are considered second-line treatment 1
• Short-acting inhaled beta2-agonist as needed for symptom relief 1

Moderate Persistent Asthma (Step 3)

• Low to medium-dose inhaled corticosteroids plus long-acting beta2-agonist (LABA) as preferred therapy 1
• Alternative option: Medium-dose inhaled corticosteroids alone (particularly for children under 5 years) 1
• Adding LABA to ICS is more effective than increasing ICS dose alone 1, 2
• Short-acting inhaled beta2-agonist as needed for symptom relief 1

Severe Persistent Asthma (Step 4)

• High-dose inhaled corticosteroids plus long-acting beta2-agonist 1
• Consider adding oral corticosteroids if needed 1
• Short-acting inhaled beta2-agonist as needed for symptom relief 1

Key Medication Considerations

Inhaled Corticosteroids (ICS)

• Most effective anti-inflammatory medication for asthma control 1, 3
• Consistently improve asthma symptoms more effectively than any other single long-term control medication 1
• Standard daily dose of 200-250 μg of fluticasone propionate or equivalent provides 80-90% of maximum therapeutic benefit 4
• Suppress inflammation in asthmatic airways and inhibit almost every aspect of the inflammatory process 3, 5

Long-Acting Beta2-Agonists (LABAs)

• Should never be used as monotherapy for asthma control due to safety concerns 1, 2
• Most effective when combined with inhaled corticosteroids 1, 6
• Preferred adjunctive therapy to ICS for patients 12 years and older 1
• Combination ICS/LABA inhalers (like Dulera or Advair) improve compliance and may reduce morbidity 2, 6

Short-Acting Beta2-Agonists (SABAs)

• Most effective therapy for rapid reversal of airflow obstruction and prompt relief of symptoms 1
• Use more than twice weekly indicates inadequate asthma control and need to step up therapy 1
• All patients with asthma should have a SABA for rescue use 1

Leukotriene Receptor Antagonists

• Alternative second-line treatment for mild persistent asthma 1
• Can be used as adjunctive therapy with ICS 1
• High compliance rates but less effective than adding LABA to ICS in patients 12 years and older 1

Acute Exacerbation Management

• Short-acting beta2-agonists via nebulizer or multiple actuations of metered dose inhaler with spacer 1
• Oral systemic corticosteroids for moderate to severe exacerbations 1
• Consider adding nebulized ipratropium for life-threatening exacerbations 1

Common Pitfalls to Avoid

• Using LABA monotherapy without ICS, which increases risk of asthma exacerbations and death 1, 2
• Failing to step up therapy when patients use rescue inhalers more than twice weekly 1
• Starting with high-dose ICS, which provides no additional clinical benefit in most efficacy parameters compared to low or moderate doses but increases risk of side effects 7
• Not providing patients with a written asthma action plan and peak flow meter for self-monitoring 1
• Discontinuing inhaled corticosteroids abruptly, which can lead to worsening asthma 1

Monitoring and Follow-up

• Monitor frequency of SABA use - more than two days per week or two nights per month indicates inadequate control 1
• Assess peak expiratory flow regularly to guide treatment decisions 1
• Develop a written asthma management plan with clear instructions on when to increase treatment or seek medical attention 1
• Consider stepping down therapy when asthma has been well-controlled for at least 3 months 1