What are the current guidelines for asthma management?

From the Guidelines

Current asthma guidelines recommend a stepwise approach to treatment based on symptom severity and control. For mild intermittent asthma, as-needed short-acting beta-agonists (SABAs) like albuterol (2 puffs every 4-6 hours as needed) are the primary treatment 1. The most recent guidelines emphasize the importance of assessing asthma control and adjusting treatment accordingly, with the goal of achieving and maintaining good control over time 1.

Key Components of Asthma Management

• Daily inhaled corticosteroids (ICS) form the cornerstone of therapy for persistent asthma, with low doses (such as fluticasone 88-220 mcg twice daily) for mild persistent asthma, increasing to medium or high doses for more severe cases 1.
• Long-acting beta-agonists (LABAs) like salmeterol or formoterol are added for moderate to severe persistent asthma, typically as combination inhalers with ICS 1.
• For severe asthma, additional controllers may include long-acting muscarinic antagonists (tiotropium 2.5 mcg daily), leukotriene modifiers (montelukast 10 mg daily for adults), or biologics targeting specific inflammatory pathways (like omalizumab, mepolizumab, or dupilumab) for those with specific phenotypes 1.
• All patients should have an asthma action plan, receive education on proper inhaler technique, and undergo regular assessment of control 1.
• Environmental trigger avoidance and treatment of comorbidities like allergic rhinitis, GERD, and obesity are also essential components of management 1.

Importance of Individualization

Asthma management should be individualized, taking into account the patient's specific needs and circumstances 1. The guidelines emphasize the importance of ongoing assessment of disease control and adjusting treatment accordingly, with the goal of achieving and maintaining good control over time 1. A stepwise approach to treatment allows for treatment intensification when control is inadequate and step-down when good control is maintained, targeting the underlying airway inflammation while providing symptom relief.

From the FDA Drug Label

1.1 Treatment of Asthma 2.1 Asthma 5.1 Serious Asthma-Related Events – Hospitalizations, Intubations, Death 5.2 Deterioration of Disease and Acute Episodes 6.1 Clinical Trials Experience in Asthma 14.1 Asthma

The current guidelines for asthma management are not explicitly stated in the provided drug label. However, the label does provide information on the treatment of asthma using salmeterol (INH), including dosage and administration and warnings and precautions.

• The label mentions serious asthma-related events, deterioration of disease, and acute episodes as important considerations in asthma management.
• It also discusses the importance of proper dosage and administration to minimize the risk of adverse effects. However, the label does not provide a comprehensive outline of current guidelines for asthma management. 2

From the Research

Current Guidelines for Asthma Management

The current guidelines for asthma management are based on a stepwise and control-based approach, involving an iterative cycle of assessment, adjustment of treatment, and review of response to minimize symptom burden and risk of exacerbations 3.

Stepwise Approach to Asthma Treatment

The stepwise approach to asthma treatment involves the following steps:

• Step 1: Intermittent asthma - as-needed short-acting β2-agonists (SABAs) for rescue therapy 4
• Step 2: Mild persistent asthma - either daily low-dose inhaled corticosteroids (ICS) plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy 4
• Step 3: Moderate persistent asthma - formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) 4
• Step 4: Moderate-severe persistent asthma - formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) 4
• Step 5: Severe persistent asthma - add-on long-acting muscarinic antagonists for individuals whose asthma is not controlled by ICS-formoterol therapy 4

Inhaled Corticosteroid Therapy

Inhaled corticosteroid therapy is the mainstay of asthma management, with the Global Initiative for Asthma guidelines recommending the use of low, medium, and high doses of ICS to define daily maintenance doses 5. However, a concise clinical review proposes that this terminology is not evidence-based and that prescribing practice based on this terminology may lead to the use of inappropriately excessive doses of ICS 5.

Key Recommendations

Key recommendations for asthma management include:

• Using daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy for mild persistent asthma 4
• Using formoterol in combination with an ICS in a single inhaler for moderate persistent asthma 4
• Avoiding the use of short-acting β2-agonists alone for mild asthma 6
• Using allergen mitigation strategies for individuals with exposure and relevant sensitivity or symptoms 4
• Considering subcutaneous immunotherapy as an adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens 4

Important Considerations

Important considerations for asthma management include:

• The risks of excessive SABA use and the benefits of regular treatment with inhaled corticosteroids 6
• The need to modify asthma guidelines and clinician prescribing practice in accordance with the currently available evidence of the dose-response relationship of ICS in adult asthma 5
• The importance of fractional exhaled nitric oxide testing to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma 4