Recommended Treatment for Managing Asthma
The cornerstone of asthma management is inhaled corticosteroids (ICS) as first-line controller therapy for persistent asthma, with short-acting beta-agonists (SABA) used as needed for symptom relief. 1, 2
Stepwise Approach to Treatment
Step 1: Mild Intermittent Asthma
- Use as-needed short-acting beta-agonists (SABA) for symptom relief 3
- No daily controller medication is needed 1
- Increasing use of SABA more than twice weekly indicates need for controller therapy 1
Step 2: Mild Persistent Asthma
- Low-dose inhaled corticosteroids (ICS) are the preferred controller treatment 1, 2
- Alternative options include leukotriene receptor antagonists or cromoglycate, though these are less effective than ICS 1
- ICS should be taken daily on a long-term basis to achieve and maintain symptom control 1
Step 3: Moderate Persistent Asthma
- Low-dose ICS plus long-acting beta-agonists (LABA) is the preferred treatment 1
- Alternative option: Medium-dose ICS monotherapy 1, 3
- Important: LABAs should never be used as monotherapy and must always be combined with ICS 1, 4
Step 4: Severe Persistent Asthma
- Medium to high-dose ICS plus LABA is the preferred treatment 1, 3
- For patients aged 12 years or older with allergic asthma inadequately controlled on high-dose ICS plus LABA, consider adding omalizumab (anti-IgE therapy) 1
Acute Exacerbation Management
Assessment of Severity
- Mild exacerbation: Normal speech, pulse <110/min, respiratory rate <25/min, PEF >50% predicted 1, 2
- Severe exacerbation: Cannot complete sentences, pulse >110/min, respiratory rate >25/min, PEF <50% predicted 1, 2
- Life-threatening: Silent chest, cyanosis, poor respiratory effort, confusion, exhaustion 2
Treatment of Exacerbations
- Mild exacerbations: Nebulized SABA (salbutamol 5mg or terbutaline 10mg) 1, 3
- Moderate to severe exacerbations: Oral systemic corticosteroids (prednisolone 30-60mg), oxygen if available, and nebulized SABA 1
- Consider hospital admission for life-threatening features, severe features persisting after initial treatment, or PEF <33% after treatment 2
Medication Effectiveness and Considerations
Inhaled Corticosteroids
- ICS are the most potent and consistently effective long-term control medications for asthma 1, 5
- They suppress virtually every step of inflammation in asthmatic airways 5, 6
- The dose-response curve is relatively flat, with minimal additional benefit from high doses in most patients 5, 7
- Low-dose ICS is sufficient for most patients with mild persistent asthma 7
Beta-Agonists
- Short-acting beta-agonists are the most effective therapy for rapid reversal of airflow obstruction 1
- Long-acting beta-agonists should never be used as monotherapy due to increased risk of asthma exacerbations and death 1, 4
- LABA combined with ICS is more effective than doubling the dose of ICS in moderate persistent asthma 8
Delivery Devices
- Consider nebulized therapy for young children, elderly patients, or those unable to use handheld inhalers properly 9
- Spacer devices can improve delivery of medication from metered-dose inhalers 1
- Check inhaler technique regularly as part of follow-up 2, 3
Self-Management and Monitoring
- Provide patients with a written action plan with clear instructions for medication adjustment 2, 3
- Teach patients to distinguish between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 2
- Monitor peak expiratory flow (PEF) regularly to assess response to treatment 2, 3
- Consider step-down of therapy when asthma has been stable for at least 3 months 2, 3
Common Pitfalls to Avoid
- Overreliance on bronchodilators without anti-inflammatory treatment 2, 3
- Underestimating severity of exacerbations 2
- Delayed administration of systemic corticosteroids during severe exacerbations 2
- Using sedatives in acute asthma (contraindicated) 10
- Failure to provide patients with written action plans for self-management 3