What is the recommended pharmacological management for asthma?

Pharmacological Management of Asthma

Asthma pharmacotherapy should follow a stepwise approach using inhaled corticosteroids (ICS) as the foundation of treatment, with short-acting beta-2 agonists (SABAs) reserved for symptom relief—never as monotherapy—and treatment intensity adjusted based on severity and control.

Core Treatment Principles

Reliever Medications

• Short-acting beta-2 agonists (albuterol/salbutamol) are the preferred reliever medications for acute symptom relief 1, 2
• Albuterol is specifically preferred due to its excellent safety profile and extensive safety data 1
• Critical caveat: SABAs should NEVER be used alone without concurrent ICS therapy 3
• For acute severe asthma, nebulized salbutamol 5 mg or terbutaline 10 mg should be administered immediately 1

Controller Medications - Stepwise Approach

Step 1: Mild Intermittent Asthma

• As-needed low-dose ICS-formoterol (maintenance and reliever therapy approach) 1
• Alternative: SABA as needed ONLY if ICS is initiated simultaneously 1

Step 2: Mild Persistent Asthma

• Daily low-dose inhaled corticosteroids are the preferred first-line controller treatment 1, 2
• 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 options (less preferred): cromolyn, leukotriene receptor antagonists, or theophylline 1

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta-2 agonist (LABA) is the preferred combination 1, 2
• Alternative: medium-dose ICS alone 1
• Single maintenance and reliever therapy (SMART) using ICS-formoterol for both maintenance and rescue is preferred for adults and adolescents due to superior reduction in severe exacerbations 2, 3

Step 4: Severe Persistent Asthma

• High-dose ICS plus LABA is the preferred treatment 1, 2
• Consider adding long-acting muscarinic antagonists (LAMA) or leukotriene receptor antagonists 2
• Oral corticosteroids may be necessary, preferably at minimal doses on alternate days 4

Step 5: Severe Uncontrolled Asthma

• Continue high-dose ICS-LABA combination 2
• Add-on treatments (LAMA, theophylline, leukotriene antagonists) should be initiated before phenotype-specific biologic therapy 3
• Consider biologic agents for severe allergic or eosinophilic asthma 2, 3
• Specialty referral is mandatory 2

Acute Exacerbation Management

Severity Assessment

Severe asthma features requiring immediate treatment 1:

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow (PEF) <50% predicted or personal best

Life-threatening features 1:

• PEF <33% predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, exhaustion, confusion, or coma
• Normal or elevated PaCO2 (5-6 kPa) in a breathless patient
• Severe hypoxia: PaO2 <8 kPa despite oxygen

Immediate Treatment Protocol

1. High-dose inhaled beta-agonists: Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen 1
2. High-dose systemic corticosteroids: Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg immediately 1
3. If life-threatening features present 1:
   • Add nebulized ipratropium 0.5 mg to beta-agonist
   • Consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 mcg over 10 minutes
   • Do NOT give bolus aminophylline to patients already taking oral theophyllines 1

Monitoring and Ongoing Management

• Measure PEF 15-30 minutes after initial treatment 1
• Continue oxygen therapy 1
• If improving: nebulized beta-agonist every 4 hours 1
• If not improving after 15-30 minutes: increase nebulized beta-agonists to every 15 minutes 1

Hospital Discharge Criteria and Medications

Patients should not be discharged until 1:

• PEF >75% predicted or personal best
• Diurnal variability <25%
• No nocturnal symptoms

All discharged patients must receive 1:

• Prednisolone 30-60 mg daily for 1-3 weeks (or longer in chronic asthma) 1
• Inhaled steroids at higher dosage than before admission 1
• Inhaled/nebulized beta-agonists as needed 1
• Peak flow meter with written self-management plan 1

Special Populations

Pregnancy

• Albuterol remains the preferred SABA due to extensive safety data 1
• Budesonide is the preferred ICS with the most reassuring pregnancy data 1
• Other ICS formulations may be continued if providing good control pre-pregnancy 1
• Serial ultrasounds starting at 32 weeks for suboptimally controlled or moderate-to-severe asthma 1

Critical Warnings and Contraindications

Avoid these interventions 1:

• Antibiotics unless bacterial infection confirmed 1
• Any sedation (absolutely contraindicated) 1
• Percussive physiotherapy 1

Drug interactions 5:

• Strong CYP3A4 inhibitors (ritonavir, ketoconazole, clarithromycin) with ICS-LABA combinations increase systemic corticosteroid effects and cardiovascular adverse events 5

Cardiovascular monitoring 5:

• LABAs can cause clinically significant cardiovascular effects including tachycardia (up to 200 beats/min), arrhythmias, QTc prolongation 5
• Use with caution in patients with cardiovascular disorders, coronary insufficiency, or arrhythmias 5

Adrenal suppression risk 5:

• Patients transferring from oral to inhaled corticosteroids require slow prednisone taper (2.5 mg weekly reduction) 5
• Monitor for adrenal insufficiency symptoms: fatigue, weakness, nausea, hypotension 5