What is the summary of asthma management?

Asthma Management Summary

The cornerstone of asthma management is to assess severity to initiate therapy and assess control to adjust therapy in a stepwise approach, with inhaled corticosteroids being the most effective long-term control medication across all age groups. 1

Assessment and Monitoring

• Assess asthma severity to determine initial treatment, then regularly assess control level to adjust therapy as needed 1, 2
• Evaluate both domains of asthma control:
  • Current impairment (symptoms, lung function, activity limitations)
  • Future risk (exacerbations, progressive loss of lung function, medication side effects) 1, 2
• Use multiple measures to assess control as different measures may identify different manifestations of asthma 1, 2
• Obtain spirometry at diagnosis and at least every 1-2 years for monitoring 2
• Schedule follow-up visits: 2-6 weeks after starting therapy, 1-6 months when control is achieved, and 3 months when stepping down therapy 2

Stepwise Approach to Management

• Follow the 6-step approach to control asthma based on severity and control level 1
  • Step 1 (Intermittent): Short-acting beta-agonists (SABA) as needed 2
  • Step 2 (Mild Persistent): Low-dose inhaled corticosteroids (ICS) 2
  • Steps 3-4 (Moderate Persistent): Low-medium dose ICS plus long-acting beta-agonists (LABA) 2
  • Steps 5-6 (Severe Persistent): High-dose ICS plus LABA, consider oral corticosteroids or biologics 2
• Step up therapy if control is not achieved; step down if control is maintained for at least 3 months 1
• Before stepping up therapy, always check adherence, inhaler technique, environmental control measures, and comorbidities 1

Medications

• Inhaled corticosteroids (ICS) are the most effective long-term control medication for all age groups 1, 2
• All patients with persistent asthma need both long-term control medications and quick-relief medications 1
• Short-acting beta-agonists (SABA) are the treatment of choice for quick relief of symptoms 1
• Use of SABA more than twice weekly indicates inadequate control and need for step-up in therapy 1
• Consider medication side effects when selecting treatment options 1

Patient Education and Self-Management

• Teach patients skills to self-monitor and manage asthma 1, 2
• Provide a written asthma action plan with instructions for daily management and handling worsening asthma 1, 2
• Ensure patients understand the difference between controller and reliever medications 2
• Educate on proper inhaler technique at every visit 2
• Expand educational opportunities beyond the physician's office to pharmacies, schools, and community settings 1

Environmental Control and Comorbidities

• Use a multifaceted approach to reduce exposure to allergens and irritants; single steps are generally ineffective 1
• Advise all patients to avoid tobacco smoke exposure 1
• Consider allergen immunotherapy for patients with clear evidence of symptom-allergen relationship 1
• Identify and treat comorbid conditions that may affect asthma control:
  • Allergic rhinitis, sinusitis, GERD, obesity, obstructive sleep apnea, and psychological factors 1, 2
• Consider annual influenza vaccination for all patients over 6 months of age 1

Management of Exacerbations

• Teach patients to recognize early signs of worsening asthma 2
• For home management of exacerbations:
  • Increase SABA use as needed 2
  • Consider short course of oral corticosteroids for moderate-severe exacerbations 2
  • Monitor response and seek medical attention if symptoms worsen 2
• Refer to asthma specialist if patient has:
  • Difficulty achieving or maintaining control 1
  • Required >2 bursts of oral corticosteroids in one year 1
  • Exacerbation requiring hospitalization 1
  • Need for step 4 care or higher (step 3 or higher for children 0-4 years) 1

Special Considerations

• Children 0-4 years: Consider daily long-term control therapy for those with recurrent wheezing, risk factors for asthma, or frequent SABA use 1
• Children 5-11 years: Follow specific pediatric treatment recommendations as this age group has distinct needs 1
• Monitor growth in children on ICS therapy 3
• For severe asthma, consider referral for evaluation for biologic therapies 1