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

Assessment and Classification

• For intermittent asthma (symptoms ≤2 times/week), short-acting beta-agonists (SABA) as needed for symptom relief is the recommended treatment 1
• Patients using SABA more than twice weekly likely have persistent asthma and need controller therapy 1
• Persistent asthma requires daily controller medication, with ICS being the most effective option 1, 2

First-Line Treatment Algorithm

Step 1: Intermittent Asthma

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

Step 2: Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroids (ICS) daily 3, 1
• Alternative options:
  • Leukotriene receptor antagonists (LTRA) like montelukast or zafirlukast 3, 1
  • Cromolyn, nedocromil, or theophylline (less commonly used) 3

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS plus long-acting beta-agonist (LABA) OR medium-dose ICS 3, 1
• Alternative: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 3

Evidence Supporting ICS as First-Line Therapy

• ICS are the only currently available asthma therapy that effectively suppress the underlying airway inflammation 2, 4
• ICS not only control symptoms and improve lung function but also prevent exacerbations and may reduce asthma mortality 2
• The 2020 CHEST guidelines recommend ICS as the best therapeutic option for cough in asthma 3
• ICS consistently improve asthma symptoms more effectively than any other single long-term control medication when used regularly 1

Important Safety Considerations

• LABA should never be used as monotherapy for asthma due to increased risk of exacerbations and mortality 1, 5
• LABA should only be used in combination with ICS 3, 1
• For patients with moderate to severe asthma not controlled on ICS alone, adding a LABA is more effective than increasing the ICS dose 6, 2
• Early intervention with ICS improves outcomes in persistent asthma 1

Monitoring and Adjusting Treatment

• Increasing use of SABA more than twice weekly suggests inadequate control and the need to initiate or intensify anti-inflammatory therapy 1
• If asthma remains uncontrolled on low-dose ICS, consider:
  • Adding LABA to low-dose ICS (preferred for patients ≥12 years) 1
  • Increasing to medium-dose ICS 1
• For severe asthma (Steps 5-6), high-dose ICS-LABA combinations with consideration of biologics may be necessary 1

Special Considerations

• For acute exacerbations, oral systemic corticosteroids may be required 1
• In patients with allergic asthma, subcutaneous immunotherapy may be considered as adjunctive treatment when symptoms are controlled 1
• The dose-response curve to ICS is relatively flat, meaning that adding another class of therapy may be preferable to increasing ICS dose in moderate-to-severe asthma 2