What are the recommended treatments for asthma?

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

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 are the preferred treatment 2, 1
• Alternative options include:
  • Leukotriene receptor antagonists (LTRAs) such as montelukast or zafirlukast (second-line option with good compliance rates) 2, 1, 3
  • Cromolyn, nedocromil, or sustained-release theophylline 2, 1

Moderate Persistent Asthma

• Low to medium-dose inhaled corticosteroids plus long-acting beta2-agonist (LABA) (preferred option) 2
• Alternative: Medium-dose inhaled corticosteroids alone 2
• For children under 5 years: Medium-dose inhaled corticosteroids is preferred 2

Severe Persistent Asthma

• High-dose inhaled corticosteroids plus long-acting beta2-agonist 2, 1
• Consider adding oral corticosteroids for severe cases 2

Monitoring Treatment Effectiveness

• Increasing use of SABA more than twice weekly or more than two nights monthly suggests inadequate control and the need to intensify anti-inflammatory therapy 2, 1
• Assess peak expiratory flow (PEF) to monitor treatment response 2
• Schedule follow-up visits to evaluate symptom control and adjust medications as needed 3

Exacerbation Management

• For moderate to severe exacerbations, oral systemic corticosteroids are recommended 2, 1
• High-dose nebulized beta2-agonists (salbutamol 5 mg or terbutaline 10 mg) for acute symptoms 2
• For life-threatening features, consider adding nebulized ipratropium and intravenous aminophylline or salbutamol/terbutaline 2

Important Safety Considerations

• LABAs should never be used as monotherapy for asthma due to increased risk of exacerbations and mortality 2, 1, 4
• Combining ICS with LABA is effective and safe when ICS alone are insufficient 2
• Monitor for potential side effects of ICS including oral candidiasis, dysphonia, and potential effects on bone mineral density with long-term use 4
• Consider referral to an ophthalmologist for patients on long-term ICS therapy due to risk of glaucoma and cataracts 4

Special Populations

• For patients with increased intraocular pressure who cannot use ICS, LTRAs are a viable non-steroid alternative 3
• For patients with allergic asthma and controlled symptoms, consider subcutaneous immunotherapy as adjunctive treatment 1
• For exercise-induced bronchoconstriction, long-term control of asthma is recommended; specific medications can be prescribed if symptoms persist during exercise 2

Comorbidity Management

• Evaluate and treat comorbidities that can worsen asthma control:
  • Allergic rhinitis
  • Sinusitis
  • Gastroesophageal reflux
  • Medication sensitivities 2
• Annual influenza vaccinations are recommended for patients with persistent asthma 2

Common Pitfalls to Avoid

• Not recognizing persistent asthma requiring controller therapy (patients using SABA more than twice weekly likely need controller therapy) 1
• Delaying initiation of ICS therapy in persistent asthma (early intervention improves outcomes) 1
• Starting with excessive ICS doses (80-90% of maximum benefit is achieved with standard doses of 200-250 μg fluticasone propionate or equivalent) 5
• Using sedation during asthma exacerbations (contraindicated) 2
• Prescribing antibiotics unless bacterial infection is present 2