How should asthma medications be adjusted?

Stepwise Adjustment of Asthma Medications

Asthma medications should be adjusted based on a stepwise approach, stepping up when necessary and stepping down when possible to identify the least amount of medication required to achieve control of symptoms and prevent exacerbations. 1

Assessment of Asthma Control

• Evaluate asthma control at every visit using both domains: current impairment (symptoms, lung function, activity limitations) and future risk (exacerbations) 1
• Use validated questionnaires like Asthma Control Test (ACT) or Asthma Therapy Assessment Questionnaire (ATAQ) to assess control level 1
• Classify control as "well controlled," "not well controlled," or "very poorly controlled" based on symptoms, nighttime awakenings, interference with activities, rescue medication use, and lung function 1

Stepwise Medication Adjustment Algorithm

Step-Up Therapy (When Control Is Not Achieved)

• For "not well controlled" asthma: step up one level of therapy and reassess in 2-6 weeks 1
• For "very poorly controlled" asthma: consider short course of oral corticosteroids and step up one to two levels of therapy 1
• Before stepping up, always check:
  • Medication adherence
  • Inhaler technique (use spacers with metered-dose inhalers)
  • Environmental triggers
  • Comorbid conditions 1

Step-Down Therapy (When Control Is Maintained)

• If asthma is "well controlled" for at least three consecutive months, consider stepping down therapy 1
• Reduce medications gradually, maintaining the lowest effective dose of inhaled corticosteroids 1

Medication Selection by Severity Level

Mild Intermittent Asthma

• No daily controller medication needed
• Short-acting beta2-agonist (SABA) as needed for symptom relief 1

Mild Persistent Asthma (Step 2)

• Preferred: Low-dose inhaled corticosteroids (ICS)
• Alternative: Leukotriene modifier, cromolyn, or nedocromil 1

Moderate Persistent Asthma

• Preferred: Low to medium-dose ICS plus long-acting beta2-agonist (LABA)
• Alternative for children <5 years: Medium-dose ICS 1

Severe Persistent Asthma

• High-dose ICS plus LABA
• If needed, add oral corticosteroids
• Consider omalizumab for patients with allergies 1

Monitoring Response to Treatment

• Schedule follow-up visits every 1-6 months depending on asthma severity and control level 1
• Perform spirometry at initial assessment and at least every 1-2 years after treatment stabilization 1
• Monitor SABA use - if using more than one canister per month, increase controller therapy 1
• Review medication use, management plan, and self-management skills at each visit 1

Special Considerations

• Exercise-induced bronchoconstriction: Use pre-treatment with SABA, leukotriene receptor antagonists, or cromolyn before exercise 1
• Pregnancy: Maintain asthma control through pregnancy; inhaled corticosteroids are preferred controller medications 1
• Comorbidities: Evaluate for allergic rhinitis, sinusitis, GERD when asthma symptoms persist despite medication adjustments 1
• Severe uncontrolled asthma: Consider referral to specialist for additional therapies including biologics 2, 3

Common Pitfalls to Avoid

• Failure to step down therapy when asthma is well-controlled for extended periods 1
• Overreliance on SABA without addressing underlying inflammation with controller medications 4, 2
• Not checking inhaler technique before adjusting medications (use of spacers improves drug delivery) 1
• For home management of acute exacerbations, doubling the dose of ICS is no longer recommended 1
• Not providing patients with written asthma action plans for self-management of symptoms and exacerbations 1

Patient Education and Self-Management

• Provide a written asthma action plan detailing when to adjust medications based on symptoms and peak flow measurements 1
• Teach patients to recognize early signs of worsening asthma and how to adjust medications accordingly 1
• Annual influenza vaccination for patients with persistent asthma to prevent respiratory infections 1