What is the asthma treatment pyramid?

The Asthma Treatment Pyramid

The asthma treatment pyramid is a stepwise approach that progressively escalates therapy from as-needed short-acting bronchodilators (Step 1) through increasing doses of inhaled corticosteroids with or without additional controllers (Steps 2-4), up to high-dose combination therapy with biologics or oral corticosteroids (Steps 5-6), with treatment adjusted upward to achieve control and stepped down when stable. 1, 2

Core Principles of the Stepwise Approach

The pyramid operates on a dynamic cycle where treatment intensity is adjusted based on current asthma control rather than remaining static 1. All patients require assessment of adherence, environmental control, comorbidities, and inhaler technique at each step before escalating therapy. 1

Universal Elements Across All Steps

• Quick-relief medication: Short-acting beta-agonist as needed for all patients at every step 1, 2
• Patient education, environmental control, and comorbidity management should occur at every level 1
• Consider subcutaneous allergen immunotherapy for patients with allergic asthma at Steps 2-4 1

The Six Treatment Steps

Step 1: Intermittent Asthma

• Preferred: Short-acting beta-agonist as needed only 1, 2
• No daily controller medication required 2
• Indicated for symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, FEV₁ >80% predicted 2

Step 2: Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroid 1, 2
• Alternatives: Cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline (requires serum monitoring) 1
• Indicated for symptoms >2 days/week but not daily, nighttime awakenings 3-4 times/month 2

Step 3: Moderate Persistent (Lower Tier)

• Preferred: Low-dose inhaled corticosteroid PLUS long-acting inhaled beta-agonist, OR medium-dose inhaled corticosteroid alone 1, 2
• Alternatives: Low-dose inhaled corticosteroid PLUS leukotriene receptor antagonist, theophylline, or zileuton 1
• Critical caveat: If alternative treatment fails, discontinue it and use preferred treatment before stepping up 1

Step 4: Moderate Persistent (Higher Tier)

• Preferred: Medium-dose inhaled corticosteroid PLUS long-acting inhaled beta-agonist 1, 2
• Alternatives: Medium-dose inhaled corticosteroid PLUS leukotriene receptor antagonist, theophylline, or zileuton 1
• Indicated for daily symptoms, nighttime awakenings >1 time/week but not nightly, FEV₁ 60-80% predicted 2

Step 5: Severe Persistent Asthma

• Preferred: High-dose inhaled corticosteroid PLUS long-acting beta-agonist 1, 2
• Add: Consider omalizumab (anti-IgE) for patients with allergic asthma 1
• Indicated for symptoms throughout the day, nighttime awakenings often 7 times/week, FEV₁ <60% predicted 2

Step 6: Most Severe Asthma

• Preferred: High-dose inhaled corticosteroid PLUS long-acting beta-agonist PLUS oral corticosteroid 1, 2
• Add: Consider omalizumab for allergic asthma 1
• Alternative consideration: Before introducing oral corticosteroids, trial of high-dose inhaled corticosteroid plus long-acting beta-agonist plus leukotriene receptor antagonist, theophylline, or zileuton may be considered (though not studied in trials) 1

When to Step Up or Step Down

Stepping Up Treatment

• Step up if: Using short-acting beta-agonist ≥2 days per week for symptom relief (not exercise prevention) indicates inadequate control 1
• Step up if: Using more than one canister of short-acting beta-agonist per month 1
• Before stepping up: Always verify medication adherence, proper inhaler technique, environmental trigger control, and evaluate for comorbidities 1

Stepping Down Treatment

• Step down when: Asthma is well-controlled for at least three months 1
• Well-controlled defined as: symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, no interference with activity, FEV₁ or peak flow >80% predicted 2

Critical Pitfalls to Avoid

• Do not ignore exacerbation history: Patients requiring ≥2 courses of oral corticosteroids per year need persistent asthma treatment regardless of normal lung function 2
• Do not rely on symptoms alone: Objective lung function testing is essential to avoid misclassification 2
• Do not assess severity during acute exacerbations: This overestimates baseline severity and leads to overtreatment 2
• Recognize treatment limitations: Well-controlled asthma can only be achieved in approximately 70% of patients across severity strata, even with optimal therapy 1
• Address comorbidities: Evaluate for allergic rhinitis, sinusitis, gastroesophageal reflux, and medication sensitivities when symptoms persist despite treatment escalation 1

Important Medication Considerations

• Inhaled corticosteroids are the most effective single long-term controller medication for improving asthma control across all severity levels 2
• Theophylline requires serum concentration monitoring (target 5-15 mcg/mL) 1
• Zileuton is less desirable due to limited adjunctive therapy studies and need for liver function monitoring 1
• Annual influenza vaccination is recommended for all patients with persistent asthma 1