What is the typical approach to managing asthma?

Managing Asthma: A Stepwise Approach

Inhaled corticosteroids (ICS) are the cornerstone of asthma management for all patients with persistent asthma, with treatment intensity adjusted using a 6-step approach based on symptom control and exacerbation risk. 1

Core Treatment Principles

Foundation Therapy

• All patients with persistent asthma require daily ICS therapy as the most effective long-term control medication across all age groups 1
• Short-acting beta-agonists (SABAs) should be available for all patients as quick-relief medication 1
• Critical warning: If SABA use exceeds 2 days per week for symptom relief (excluding exercise prevention), this indicates inadequate control and necessitates stepping up therapy 1

The 6-Step Treatment Algorithm

Step 1 (Intermittent Asthma):

• SABA as needed only 1

Step 2 (Mild Persistent):

• Low-dose ICS (preferred) 1
• Alternatives: cromolyn, leukotriene receptor antagonist (LTRA), nedocromil, or theophylline 1

Step 3 (Moderate Persistent):

• Preferred: Low-dose ICS + long-acting beta-agonist (LABA) OR medium-dose ICS 1
• Alternatives: Low-dose ICS + LTRA, theophylline, or zileuton 1
• FDA Black Box Warning: LABAs must NEVER be used as monotherapy—only in combination with ICS 1

Step 4:

• Medium-dose ICS + LABA (preferred) 1
• Alternatives: Medium-dose ICS + LTRA, theophylline, or zileuton 1

Step 5:

• High-dose ICS + LABA (preferred) 1
• Consider adding omalizumab for patients ≥12 years with allergic asthma (elevated IgE, positive skin testing, inadequate control on high-dose ICS) 1

Step 6:

• High-dose ICS + LABA + oral corticosteroids 1
• Consider omalizumab for allergic asthma 1

Critical Decision Points Before Stepping Up

Before increasing medication, always verify these four factors: 1

1. Medication adherence - Is the patient actually taking prescribed medications?
2. Inhaler technique - Can the patient demonstrate proper device use?
3. Environmental control - Are triggers (smoke, allergens, irritants) being avoided?
4. Comorbid conditions - Are GERD, rhinitis, sinusitis, or obesity being addressed?

Monitoring and Adjusting Therapy

Assessing Control

Evaluate control using both impairment and risk domains: 1

Impairment indicators:

• Daytime symptoms frequency 1
• Nighttime awakenings 1
• SABA use for symptom relief 1
• Interference with normal activities 1
• Lung function (FEV1 or peak flow) 1

Risk indicators:

• Exacerbations requiring oral corticosteroids (≥2 per year indicates poor control even if symptoms seem minimal) 1
• Progressive lung function decline 1
• Medication side effects 1

Stepping Down Therapy

• Once well-controlled for at least 3 months, attempt to step down to identify the minimum effective dose 1
• This is equally important as stepping up, particularly because higher ICS doses increase risks of systemic effects (growth suppression in children, reduced bone density in adults) with minimal additional benefit 1
• Maximum clinical benefit from fluticasone occurs at 200 μg/day; doses of 500-1000 μg/day provide minimal additional improvement 1

Special Considerations

ICS Dosing Nuances

• Low-dose ICS is generally safe with benefits outweighing risks 1
• Up to one-third of patients may have corticosteroid insensitivity and won't respond adequately even to high doses 1
• When transitioning patients from oral corticosteroids to ICS, taper oral prednisone by 2.5 mg weekly while monitoring for adrenal insufficiency 2

Adjunctive Therapies

• Subcutaneous allergen immunotherapy should be considered at Steps 2-4 for patients with allergic asthma (evidence strongest for single allergens) 1
• Omalizumab reduces exacerbations in severe allergic asthma (NNT = 6) 1

Patient Education Requirements

• Every patient needs a written asthma action plan detailing daily treatment and how to recognize/handle worsening symptoms 1
• Education should occur in multiple settings: clinics, pharmacies, schools, and homes 1

Common Pitfalls to Avoid

1. Never use LABAs alone without ICS - this carries an FDA black box warning due to increased severe exacerbation risk 1
2. Don't ignore frequent SABA use - using rescue inhalers >2 days/week signals inadequate control 1
3. Don't assume symptom-free means controlled - patients can have minimal daily symptoms but still be at high risk for severe exacerbations 1
4. Don't continue high-dose ICS indefinitely - step down when stable to minimize systemic corticosteroid effects 1

When to Refer to Specialist

Refer for consultation or co-management when: 1

• Difficulty achieving or maintaining control
• ≥2 oral corticosteroid bursts in one year
• Step 4 or higher care required
• Considering immunotherapy or omalizumab
• Hospitalization for exacerbation