Asthma Treatment Guidelines
The standard treatment for asthma follows a stepwise approach, with inhaled corticosteroids (ICS) as the preferred first-line controller medication for persistent asthma due to their superior effectiveness in improving symptoms, reducing exacerbations, and preventing hospitalizations compared to any other single long-term control medication. 1
Classification and Initial Treatment
- For intermittent asthma: PRN short-acting beta-agonists (SABA) as needed for symptom relief 1
- For mild persistent asthma (Step 2): Low-dose inhaled corticosteroids are the preferred treatment 2, 1
- Alternative options for mild persistent asthma include leukotriene receptor antagonists (montelukast, zafirlukast), which offer good compliance rates but are considered second-line options 2, 1
- Other alternatives include cromolyn, nedocromil, or theophylline, though these are less commonly used 2
Stepwise Approach for Inadequate Control
Step 3
- If asthma remains uncontrolled on low-dose ICS, add a long-acting beta-agonist (LABA) to low-dose ICS or increase to medium-dose ICS 2, 1
- For patients ≥12 years old, adding LABA to ICS is preferred over increasing ICS dose alone 2, 1
Step 4
- Medium-dose ICS plus LABA is the preferred treatment 2
- Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2
Step 5-6
- High-dose ICS plus LABA 2
- Consider adding omalizumab for patients with allergic asthma 2
- For Step 6, add oral corticosteroids to high-dose ICS plus LABA 2
Quick-Relief Medications
- Inhaled short-acting beta-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms 2
- For acute exacerbations: High doses of inhaled beta-agonists (salbutamol 5 mg or terbutaline 10 mg), which may be nebulized with oxygen or given via multiple actuations of a metered dose inhaler into a spacer device 2
Warning Signs of Inadequate Control
- Increasing use of SABA more than twice weekly for symptom relief generally indicates inadequate control and the need to initiate or intensify anti-inflammatory therapy 2, 1
- Nocturnal symptoms or worsening of symptoms also indicate need for treatment adjustment 2
Safety Considerations
- LABA should never be used as monotherapy for asthma due to increased risk of exacerbations and mortality 2, 1
- LABAs should only be used in combination with ICS 2
- For combination therapy, products like fluticasone propionate/salmeterol provide coverage for both inflammatory and bronchoconstrictive aspects of asthma 3, 4
- Studies show combination treatment with ICS and LABA provides greater asthma control than increasing ICS dose alone 4, 5
Management of Exacerbations
- For moderate to severe exacerbations, oral systemic corticosteroids are recommended: 30-60 mg prednisolone or intravenous hydrocortisone 200 mg 2, 1
- For life-threatening features, add nebulized ipratropium (0.5 mg) to beta-agonist and consider intravenous aminophylline or salbutamol 2
- Antibiotics should only be given if bacterial infection is present 2
Special Considerations
- Spacer devices (valved holding chambers) markedly increase lung deposition of inhaled medications 2
- Smokers may have decreased responsiveness to corticosteroids 2
- For severe asthma uncontrolled on standard therapy, consider referral to specialists for additional treatments such as tiotropium, omalizumab, or azithromycin 6