What is the recommended pharmacological management for asthma?

Pharmacological Management of Asthma

The cornerstone of asthma pharmacotherapy is inhaled corticosteroids (ICS) combined with short-acting beta-2 agonists (SABA) or fast-acting beta agonists (FABA), with treatment intensity adjusted in a stepwise fashion based on disease severity and control. 1

Acute Severe Asthma Management

Immediate Treatment for Severe Exacerbations

For acute severe asthma (respiratory rate >25/min, heart rate >110/min, PEF <50% predicted), immediately administer high-dose nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg) with oxygen and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV). 1

• Life-threatening features (PEF <33% predicted, silent chest, cyanosis, bradycardia, confusion, or PaCO2 >6 kPa) require additional ipratropium 0.5 mg nebulized plus IV aminophylline 250 mg over 20 minutes or IV salbutamol/terbutaline 250 µg over 10 minutes 1
• Critical caveat: Never give bolus aminophylline to patients already taking oral theophyllines 1
• Sedation is absolutely contraindicated in acute asthma 1
• Antibiotics should only be given if bacterial infection is confirmed 1

Hospital Discharge Criteria and Medications

Patients should not be discharged until PEF is >75% of predicted/best, diurnal variability <25%, and nocturnal symptoms have resolved 1

All patients discharged after acute exacerbation must receive: 1

• Prednisolone 30-60 mg daily for 1-3 weeks
• Inhaled corticosteroids at higher dosage than pre-admission
• Inhaled/nebulized beta-agonists as needed
• Peak flow meter with written self-management plan

Chronic Asthma Management by Severity

Step 1: Mild Intermittent Asthma

Short-acting inhaled beta-2 agonists as needed are the preferred treatment, with albuterol being the first choice due to its excellent safety profile. 1

• Important update: Using SABA alone without ICS is no longer recommended even for mild asthma 2
• Preferred alternative: As-needed combination FABA/ICS (budesonide 200 µg/formoterol 6 µg) reduces exacerbations by 55% compared to FABA alone (OR 0.45,95% CI 0.34-0.60) 3

Step 2: Mild Persistent Asthma

Daily low-dose inhaled corticosteroids are the preferred long-term controller medication. 1

• Budesonide is the preferred ICS due to the most extensive safety data, though other ICS formulations are acceptable if already providing good control 1
• Alternative but not preferred options include cromolyn, leukotriene receptor antagonists, or theophylline 1, 4
• As-needed FABA/ICS combination therapy is equally effective as regular ICS (OR 0.79,95% CI 0.59-1.07 for exacerbations) while reducing average daily ICS exposure by 154 µg/day 3

Step 3: Moderate Persistent Asthma

Low-dose ICS plus long-acting beta-2 agonists (LABA) are the preferred controller treatment. 1

• Alternative: Medium-dose ICS alone 1
• Single maintenance and reliever therapy (SMART) using ICS/formoterol both as maintenance and as-needed is preferred for adults and adolescents due to superior reduction in severe exacerbations 5, 2

Step 4-5: Severe Persistent Asthma

High-dose ICS plus LABA are required, with consideration of add-on treatments before initiating phenotype-specific biologics. 1, 2

• Additional options include oral theophylline, long-acting muscarinic antagonists, or leukotriene receptor antagonists 1, 5
• Oral corticosteroids may be needed at minimal dose, preferably alternate-day 1, 4
• Biologic agents should be considered for severe allergic or eosinophilic asthma uncontrolled despite appropriate treatment 5, 2

Critical Safety Considerations

Systemic Corticosteroid Withdrawal

When transferring patients from oral to inhaled corticosteroids, reduce prednisone by 2.5 mg weekly while monitoring lung function, beta-agonist use, and symptoms. 6

• Monitor for adrenal insufficiency (fatigue, weakness, nausea, hypotension) 6
• Patients may need supplementary systemic corticosteroids during stress or severe attacks 6

Drug Interactions and Adverse Effects

Strong CYP3A4 inhibitors (ritonavir, ketoconazole, itraconazole) should not be used with ICS/LABA combinations due to increased systemic corticosteroid effects and cardiovascular adverse events. 6

• High-dose ICS can cause HPA axis suppression equivalent to oral prednisone 5 mg daily 1
• Beta-agonists may cause cardiovascular effects including tachycardia, arrhythmias, QTc prolongation, and hypertension 6
• Severe milk protein allergy is an absolute contraindication to dry powder inhalers containing lactose 6

Special Populations

Pregnancy

Budesonide is the preferred ICS during pregnancy with the most reassuring safety data, though other ICS formulations may be continued if providing good control 1

• Albuterol is the preferred SABA with extensive safety data in pregnancy 1
• Asthma control is critical: serial ultrasounds starting at 32 weeks should be considered for suboptimally controlled or moderate-to-severe asthma 1

Monitoring and Follow-Up

Assess asthma control at every visit using validated tools (Asthma Control Test or asthma APGAR), measure peak flow or spirometry, and verify inhaler technique. 5, 4

• Follow-up every 8-12 weeks for stable patients 4
• Step down therapy after prolonged control; step up if inadequately controlled 1, 5
• All patients should have written action plans and peak flow meters 1