What are the treatment guidelines for asthma?

Asthma Treatment Guidelines

Asthma management follows a stepwise approach prioritizing inhaled corticosteroids (ICS) as the foundation of treatment, with escalation to combination ICS/long-acting beta-agonist (LABA) therapy for patients not controlled on low-dose ICS alone. 1

Core Treatment Goals

The primary objectives of asthma management are to 1:

• Abolish symptoms and restore normal or best possible airway function
• Reduce risk of severe attacks and minimize absence from work or school
• Use the lowest effective doses of medications to minimize side effects
• Enable normal growth in children

Stepwise Treatment Algorithm

Mild Intermittent Asthma

• As-needed short-acting β2-agonists (SABA) alone for symptom relief 1
• Ensure proper inhaler technique and patient understanding of when to use rescue medication 2

Mild Persistent Asthma

• Low-dose inhaled corticosteroids (ICS) as first-line controller medication 1, 3
• Continue as-needed SABA for symptom relief 1
• Alternative emerging strategy: As-needed combination FABA/ICS (budesonide 200 μg/formoterol 6 μg) instead of SABA alone, which reduces exacerbations requiring systemic steroids (52 vs 109 per 1000 patients) and likely reduces emergency department visits 4
• Daily low-dose ICS is more effective than intermittent ICS given only during exacerbations 5

Moderate Persistent Asthma

• Low-dose ICS plus LABA combination therapy is preferred over doubling or quadrupling ICS dose 3, 5
• Fluticasone/salmeterol 100/50 μg twice daily is the standard starting combination 6, 7
• Alternative options include low-dose ICS plus leukotriene receptor antagonist, though combination ICS/LABA is superior 8

Severe Persistent Asthma

• Medium-to-high dose ICS plus LABA 3
• Fluticasone/salmeterol 250/50 μg or 500/50 μg twice daily depending on severity 6
• Consider adding leukotriene modifiers, theophylline, or biologic agents (omalizumab for allergic asthma) 3
• Oral corticosteroids may be necessary for step 6 treatment 3

Pediatric Considerations (Ages 4-11)

• Fluticasone/salmeterol 100/50 μg twice daily for those requiring combination therapy 6
• Consider daily controller therapy for children with ≥2 wheezing episodes in the past year lasting >1 day, especially with risk factors (parental asthma, atopic dermatitis) 3
• Monitor growth regularly as high-dose ICS may reduce linear growth rate 1

Acute Exacerbation Management

Severity Assessment

Assess and document 2, 1:

• Ability to speak in complete sentences
• Respiratory rate (>25/min indicates severe)
• Heart rate (>110/min indicates severe)
• Peak expiratory flow (PEF) as percentage of predicted or personal best

Mild Exacerbation (PEF >50% predicted)

• Nebulized salbutamol 5 mg or terbutaline 10 mg 2
• Monitor response at 15-30 minutes 2
• If PEF 50-75% after treatment: Give prednisolone 30-60 mg and step up usual treatment 2
• If PEF >75%: Step up usual treatment without systemic steroids 2
• Follow-up within 48 hours 2

Severe Exacerbation (PEF <50% predicted, cannot complete sentences, pulse >110, RR >25)

• Oxygen 40-60% immediately 2
• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas 2
• Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg 2
• Add ipratropium 0.5 mg nebulized for additional bronchodilation 2, 9
• Reassess at 15-30 minutes 2
• Arrange hospital admission if any severe features persist after initial treatment, especially if PEF <33% 2

Life-Threatening Features (Immediate Hospitalization Required)

• Silent chest, cyanosis, poor respiratory effort 2, 1
• Bradycardia, hypotension, confusion, exhaustion, or coma 2
• Immediate treatment: Oxygen, nebulized bronchodilators, IV hydrocortisone 200 mg, consider IV aminophylline 250 mg over 20 minutes 2
• Chest radiography to exclude pneumothorax 2
• Patient must be accompanied by nurse or doctor at all times 2

Lower Threshold for Admission

• Attack occurring in afternoon or evening 2
• Recent nocturnal symptoms or hospital admission 2
• Previous severe attacks or patient concern 2
• Poor social circumstances or inability to assess own condition 2

Stepping Down Treatment

Once asthma is well-controlled for at least 3 months, consider stepping down therapy 1, 3:

• For patients controlled on FSC 250/50 μg twice daily: Step down to FSC 100/50 μg twice daily rather than switching to ICS alone, as this maintains better control (morning PEF difference of 12.9 L/min favoring continued combination therapy) 10
• Use the lowest effective ICS dose to minimize side effects 1

Self-Management Education

Every patient must receive 1, 3:

• Written asthma action plan with clear instructions for medication adjustment 1
• Understanding of "relievers" (bronchodilators) vs "preventers" (anti-inflammatory medications) 1, 3
• Peak flow meter and instruction on twice-daily monitoring 2, 1
• Recognition of worsening symptoms requiring urgent medical attention 1
• Proper inhaler technique verification 2

Critical Pitfalls to Avoid

Common errors that increase morbidity and mortality 2, 1, 3:

• Underuse of corticosteroids - Many asthma deaths are preventable with appropriate steroid use 2
• Overreliance on bronchodilators without anti-inflammatory treatment 1, 3
• Underestimating severity of exacerbations - Patients may not exhibit all abnormal findings even in severe attacks 2
• Delayed administration of systemic corticosteroids during severe exacerbations 1, 3
• Using sedation in acute asthma 3
• Prescribing LABA monotherapy without ICS - This increases risk of serious asthma-related events 6
• Combining multiple LABA-containing medications - Risk of overdose 6

Monitoring and Follow-Up

After Acute Exacerbations

• Follow-up within 24 hours for severe exacerbations, 48 hours for moderate 2
• Continue prednisolone course for 3-10 days total 1
• Patients should not be discharged until PEF >75% of predicted/personal best 2, 1

Routine Monitoring

• Regular review of inhaler technique, adherence, and symptom control 1, 3
• Assess bone mineral density initially and periodically with long-term ICS use 6
• Monitor for oral candidiasis - advise rinsing mouth after ICS use 6
• Consider ophthalmology referral for patients on long-term ICS (glaucoma/cataract risk) 6
• Watch for pneumonia in COPD patients on ICS/LABA 6

Special Medication Considerations

ICS/LABA Combination Therapy

• Fluticasone/salmeterol twice daily is more effective than once daily dosing for maintaining 24-hour lung function improvements 7
• Single-inhaler combination ensures symptomatic relief is accompanied by anti-inflammatory therapy 5, 4
• Average daily ICS exposure is lower with as-needed FABA/ICS compared to regular ICS (154 μg/day less) 4

Drug Interactions

• Strong cytochrome P450 3A4 inhibitors increase fluticasone exposure - use with caution 6
• Exercise caution in patients already taking theophyllines before adding aminophylline 2