What is the typical line of treatment for asthma?

Asthma Treatment Guidelines

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent asthma as they improve asthma control more effectively than any other single long-term control medication when used consistently. 1, 2

Stepwise Approach to Asthma Management

Initial Assessment and Classification

• Asthma treatment follows a stepwise approach based on severity classification (intermittent, mild persistent, moderate persistent, or severe persistent) 1
• Proper care involves systematic chronic care plans, self-management support, and appropriate medical therapy 1

Step 1: Intermittent Asthma

• For intermittent asthma, use short-acting beta-agonists (SABA) as needed for symptom relief 1, 2
• No controller medication is needed for truly intermittent asthma 1
• Occasional severe exacerbations should be treated with short courses of oral corticosteroids 1

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroids are the preferred controller treatment 1, 2
• Alternative second-line options include leukotriene receptor antagonists (LTRAs), which have high compliance rates and provide good symptom control in many patients 1
• Other alternatives include cromoglycate, nedocromil, or sustained-release theophylline 1, 2

Step 3: Moderate Persistent Asthma

• Low-dose inhaled corticosteroids plus long-acting beta-agonists (LABAs) are the preferred controller treatment 1, 2
• Alternatively, medium-dose inhaled corticosteroids may be used 1
• For patients ≥12 years old, adding a LABA to ICS is preferred over increasing ICS dose alone 2

Step 4: Severe Persistent Asthma

• High-dose inhaled corticosteroids plus long-acting beta-agonists are the preferred treatment 1, 2
• Oral corticosteroids may also be needed for severe persistent asthma 1

Rescue Medications and Exacerbations

• Inhaled short-acting beta-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms 1
• Increasing use of short-acting beta-agonists more than two days per week or more than two nights per month indicates inadequate control and need to initiate or intensify anti-inflammatory therapy 1, 2
• Oral systemic corticosteroids should be used to treat moderate to severe asthma exacerbations 1, 2

Important Safety Considerations

• LABAs should never be used as monotherapy for asthma due to increased risk of exacerbations and death 2, 3
• When inhaled corticosteroids alone are insufficient, combining LABAs with ICS is effective and safe 1
• Patients with severe exacerbations may require hospitalization, especially with life-threatening features such as altered consciousness, hypoxia, or elevated PaCO2 1

Monitoring and Treatment Adjustment

• Monitor peak expiratory flow to assess airway obstruction objectively 1
• Patients should not be discharged from care until symptoms have stabilized or returned to normal function, with peak expiratory flow above 75% of predicted value 1
• A one to three month period of stability should be shown before stepwise reduction in treatment is undertaken 1

Common Pitfalls to Avoid

• Not recognizing when intermittent asthma has progressed to persistent asthma - patients using SABA more than twice weekly likely need controller therapy 2
• Delaying initiation of ICS therapy in persistent asthma, as early intervention improves outcomes 2
• Using LABAs as monotherapy, which increases risk of exacerbations and mortality 2, 3
• Inadequate patient education about proper inhaler technique and medication adherence 1
• Failing to identify and address environmental triggers that may worsen asthma symptoms 1