What is the recommended treatment for asthma using controlled inhalers, such as inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA)?

Treatment of Asthma with Controlled Inhalers

The recommended treatment for asthma using controlled inhalers follows a stepwise approach, with inhaled corticosteroids (ICS) as the cornerstone therapy for persistent asthma and the addition of long-acting beta-agonists (LABA) for patients not adequately controlled on ICS alone. 1

Stepwise Approach to Asthma Management

Step 1: Mild Intermittent Asthma

• Preferred treatment: As-needed short-acting beta-agonist (SABA) 1
• Each step includes patient education, environmental control, and management of comorbidities 1

Step 2: Mild Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroid (ICS) daily 1
• Alternative treatments: Leukotriene receptor antagonists (montelukast, zafirlukast), cromolyn, nedocromil, or theophylline 1
• Leukotriene modifiers have advantages of ease of use and high compliance rates 1

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-dose ICS plus long-acting beta-agonist (LABA) OR medium-dose ICS 1
• Alternative treatment: Low-dose ICS plus either leukotriene receptor antagonist, theophylline, or zileuton 1
• The combination of ICS and LABA provides complementary effects, with ICS increasing beta2-receptor expression and LABA potentially enhancing corticosteroid actions 2

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred treatment: Medium-dose ICS plus LABA 1
• Alternative treatment: Medium-dose ICS plus either leukotriene receptor antagonist, theophylline, or zileuton 1
• Using SABA more than twice weekly for symptom relief indicates inadequate control and need to step up treatment 1

Step 5: Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA 1
• Consider adding omalizumab for patients with allergies 1

Step 6: Very Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA plus oral corticosteroid 1
• Consider omalizumab for patients with allergies 1

Key Considerations for Controlled Inhaler Use

ICS Therapy

• ICS forms the basis for treatment of asthma of all severities, improving asthma control, lung function, and preventing exacerbations 3
• Standard daily dose of ICS (200-250 μg fluticasone propionate or equivalent) achieves 80-90% of maximum therapeutic benefit 4
• Local side effects include oral candidiasis, hoarseness, and dysphonia; systemic side effects usually occur only at doses above maximum recommended doses 3

LABA Therapy

• LABAs should never be used as monotherapy for asthma due to increased risk of asthma-related events including deaths 3, 1
• LABAs provide bronchodilation and also inhibit mast cell mediator release, plasma exudation, and may reduce sensory nerve activation 2
• Combination ICS/LABA therapy in a single inhaler represents a safe, effective, and convenient treatment option 5

ICS/LABA Combinations

• Fluticasone/salmeterol (Advair) and budesonide/formoterol are effective combination therapies 2, 6
• Combination therapy is indicated for patients not adequately controlled on ICS alone or whose disease warrants initiation of both ICS and LABA 7
• Wixela Inhub (fluticasone/salmeterol) is indicated for twice-daily treatment of asthma in patients aged 4 years and older 7

Important Clinical Pearls

• Assess asthma control regularly and adjust therapy accordingly 1
• Step up if needed (first check adherence, inhaler technique, and environmental control) 1
• Step down if possible when asthma is well-controlled for at least three months 1
• After inhalation, patients should rinse their mouth with water without swallowing to reduce risk of oral candidiasis 7
• More frequent administration or greater number of inhalations than prescribed is not recommended due to increased risk of adverse effects 7
• Patients using ICS/LABA combinations should not use additional LABA for any reason 7

Common Pitfalls to Avoid

• Using LABA monotherapy for asthma treatment increases risk of asthma-related events including deaths 1, 3
• Excessive ICS dosing beyond what is needed for control can lead to unnecessary side effects 4
• Failing to step up therapy when a patient uses rescue SABA more than twice weekly (indicates inadequate control) 1
• Not considering comorbidities and environmental factors before increasing medication doses 1
• Inadequate patient education on proper inhaler technique, which can significantly reduce medication effectiveness 1