Treatment of Bronchial Asthma
Inhaled corticosteroids (ICS) are the cornerstone of treatment for persistent asthma, as they are the most potent and consistently effective long-term control medication available. 1, 2
Assessment and Classification
- Determine asthma severity based on symptom frequency, nighttime awakenings, and lung function to guide initial treatment 1
- Increasing use of short-acting beta2-agonists (SABA) more than twice weekly or nighttime symptoms more than twice monthly indicates inadequate control and need for initiating or intensifying anti-inflammatory therapy 3, 2
- Regular assessment of symptom control and medication adherence is essential for optimal management 1
First-Line Treatment
- For mild intermittent asthma: as-needed SABA for symptom relief 2
- For persistent asthma (mild, moderate, or severe): daily low-dose ICS is the preferred initial controller medication 1, 2
- ICS consistently improve asthma symptoms, reduce exacerbation rates, decrease symptom frequency, and reduce need for supplemental SABA more effectively than any other single long-term control medication 3, 4
- Proper inhaler technique is crucial for medication effectiveness; consider using spacers with metered-dose inhalers to increase lung deposition 3
Step-Up Therapy for Inadequate Control
- For patients not adequately controlled on low-dose ICS, add a long-acting beta2-agonist (LABA) to ICS or increase to medium-dose ICS 5, 2
- For patients ≥12 years old, adding LABA to ICS is preferred over increasing ICS dose alone 3, 2
- For moderate-to-severe persistent asthma, ICS-LABA combination therapy is the preferred treatment 3, 5
- For severe asthma (Step 5-6), high-dose ICS-LABA combinations with consideration of biologics may be necessary 2
- Long-acting muscarinic antagonists (LAMAs) can be added as adjunctive therapy for patients ≥5 years old on step 5 therapy 3
Alternative Controller Options
- Leukotriene receptor antagonists (LTRAs) are an alternative, though not preferred, treatment option for mild persistent asthma 3, 2
- LTRAs may be more effective in some patients due to better compliance 3, 5
- LTRAs can also be used as adjunctive therapy with ICS for moderate persistent asthma 3, 6
Acute Exacerbations
- Oral systemic corticosteroids should be used to treat moderate to severe asthma exacerbations 3, 2
- For adults: 40-60 mg per day in one or two divided doses for 5-10 days 3
- For children: 1-2 mg per kg per day for 3-10 days 3
- Tapering is not necessary for short courses of systemic corticosteroids 3
Important Safety Considerations
- LABAs should NEVER be used as monotherapy for asthma due to increased risk of exacerbations and death 3, 2
- Always use LABAs in combination with ICS 7
- Monitor for potential side effects of ICS, including oral candidiasis (thrush) and dysphonia 3, 7
- Advise patients to rinse their mouth with water without swallowing after ICS inhalation to reduce risk of oral candidiasis 7
- High-dose ICS may have systemic effects with long-term use, including potential impacts on bone mineral density 7
Common Pitfalls to Avoid
- Using LABAs as monotherapy, which increases risk of asthma-related events including death 2, 7
- Delaying initiation of ICS therapy in persistent asthma, as early intervention improves outcomes 2
- Confusing intermittent with persistent asthma - patients using SABA more than twice weekly likely need controller therapy 2
- Underestimating the importance of proper inhaler technique, which can significantly reduce medication effectiveness 1, 5
- Starting with high-dose ICS, which provides no additional clinical benefit in most efficacy parameters compared to low or moderate doses but may have increased safety concerns 8
By following this evidence-based approach to bronchial asthma treatment, clinicians can effectively manage symptoms, prevent exacerbations, and improve quality of life for patients with asthma.