Recommended Treatments for Asthma
Inhaled corticosteroids (ICS) are the preferred first-line controller medication for persistent asthma due to their superior effectiveness in improving asthma control compared to any other single long-term control medication. 1, 2
Treatment Based on Asthma Severity
Intermittent Asthma
- Short-acting beta2-agonists (SABA) as needed for symptom relief 1
- No daily controller medication needed 2
Mild Persistent Asthma
- Low-dose inhaled corticosteroids as preferred daily controller therapy 2, 1
- Alternative options include leukotriene receptor antagonists (LTRAs), which offer ease of use and high compliance rates but are generally less effective than ICS 2, 1
- Other alternatives: cromolyn, nedocromil, or sustained-release theophylline 2, 1
Moderate Persistent Asthma
- Low to medium-dose inhaled corticosteroids plus long-acting beta2-agonist (LABA) as preferred therapy 2, 1
- Alternative: Medium-dose inhaled corticosteroids alone 2
- For children under 5 years, medium-dose inhaled corticosteroids are preferred 2
Severe Persistent Asthma
- High-dose inhaled corticosteroids plus long-acting beta2-agonist 2, 1
- Consider adding oral corticosteroids if needed 2
- Consider biologics for appropriate candidates with severe asthma 1
Quick-Relief Medications
- Short-acting inhaled beta2-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of symptoms 2
- Increasing use of SABA more than twice weekly for symptom relief generally indicates inadequate control and the need to initiate or intensify anti-inflammatory therapy 2, 1
Exacerbation Management
- Oral systemic corticosteroids are recommended for moderate to severe asthma exacerbations 2, 1
- High-dose inhaled beta-agonists (salbutamol 5 mg or terbutaline 10 mg) via nebulizer or multiple actuations of metered-dose inhaler with spacer 2
- Consider adding ipratropium nebulized to beta-agonist for life-threatening exacerbations 2
Important Safety Considerations
- LABA should never be used as monotherapy for asthma due to increased risk of exacerbations and mortality 2, 1
- ICS-LABA combinations are effective and safe when ICS alone are insufficient 2
- Monitor for potential side effects of long-term ICS use, including oral candidiasis, dysphonia, and potential effects on bone mineral density 2, 3
- Glaucoma and cataracts may occur with long-term use of inhaled corticosteroids; consider ophthalmology referral for patients on long-term therapy 3
Monitoring and Treatment Adjustment
- Assess asthma control at regular intervals 2
- Step up therapy if control is inadequate (increased symptoms, increased rescue medication use, decreased lung function) 2, 1
- Step down therapy if good control is maintained for at least 3 months 1
- Monitor peak expiratory flow as an objective measure of airflow obstruction 2
Special Considerations
- For patients with increased intraocular pressure or other contraindications to ICS, LTRAs provide a viable non-steroid alternative 4
- For exercise-induced bronchoconstriction, long-term control of asthma is recommended; specific medications can be prescribed if symptoms persist during exercise 2
- Treat comorbid conditions that may exacerbate asthma, including allergic rhinitis, sinusitis, and gastroesophageal reflux 2
- Annual influenza vaccinations are recommended for patients with persistent asthma 2
Pitfalls to Avoid
- Not recognizing persistent asthma: patients using SABA more than twice weekly likely need controller therapy 1
- Delaying initiation of ICS therapy in persistent asthma, as early intervention improves outcomes 1
- Using LABA without concurrent ICS therapy 2, 1
- Inadequate treatment of exacerbations; oral corticosteroids should not be delayed for moderate to severe exacerbations 2
- Sedation is contraindicated in acute asthma management 2