What are the next steps for escalating asthma treatment in a patient currently using rescue albuterol (bronchodilator)?

From the Guidelines

When a patient's asthma is not adequately controlled with rescue albuterol alone, treatment should be escalated to include a low-dose inhaled corticosteroid (ICS) such as fluticasone, budesonide, or beclomethasone, as this step-up approach addresses the underlying inflammation rather than just symptom relief, according to the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma 1.

Key Considerations for Escalation

• The primary goal of escalating treatment is to achieve and maintain control of persistent asthma by reducing airway hyperresponsiveness and inflammation.
• Inhaled corticosteroids (ICS) are the most consistently effective long-term control medication for persistent asthma, improving asthma control more effectively than leukotriene receptor antagonists (LTRAs) or any other single long-term control medication 1.
• If symptoms persist despite adherence to ICS therapy, the next step would be either increasing the ICS dose or adding a long-acting beta-agonist (LABA) such as salmeterol or formoterol, often available in combination inhalers like Advair or Symbicort.

Additional Options for Difficult-to-Control Asthma

• For patients with more severe or difficult-to-control asthma, additional options include:
  • Adding a long-acting muscarinic antagonist like tiotropium (Spiriva Respimat) 1.
  • A leukotriene modifier such as montelukast (10 mg daily for adults) 1.
  • Considering biologics for specific asthma phenotypes.

Monitoring and Follow-Up

• Throughout this escalation, patients should continue to have access to their rescue albuterol inhaler for breakthrough symptoms.
• If patients are using their rescue inhaler more than twice weekly, it indicates their asthma is not well-controlled, and further adjustment is needed 1.
• Regular follow-up every 2-3 months is essential to assess control and adjust therapy accordingly, ensuring that the treatment plan is optimized for the best possible outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Escalating Asthma Treatment

For a patient currently using rescue albuterol (bronchodilator) and requiring escalation of treatment, the following steps can be considered:

• Adding a long-acting β2 agonist (LABA) to an inhaled corticosteroid (ICS) is the preferred treatment for patients who fail to achieve symptom control using a medium dose of ICS alone 2
• Single maintenance and reliever therapy, which combines an ICS and LABA for controller and reliever treatments, is preferred for adults and adolescents due to its effectiveness in reducing severe exacerbations 3
• Treatment typically begins with ICS, and additional medications or dosage increases should be added in a stepwise fashion according to guideline-directed therapy recommendations 3

Treatment Options

The following treatment options can be considered for escalating asthma treatment:

• Budesonide/formoterol (BUD/FM) for maintenance and reliever therapy (SMART) 2
• Fluticasone propionate/salmeterol (FP/SM) fixed-dose treatment 2
• Salmeterol/fluticasone propionate combination (SFC) 4
• Inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs) in a single inhaler 5

Considerations

When escalating asthma treatment, the following considerations should be taken into account:

• Asthma severity and level of control should be assessed at diagnosis and evaluated at subsequent visits using validated tools 3
• Patients with severe uncontrolled asthma despite appropriate treatment should be reassessed and considered for specialty referral 3
• Biologic agents may be considered for patients with severe allergic and eosinophilic asthma 3