Management of Uncontrolled Asthma
Before stepping up therapy in uncontrolled asthma, you must first review medication adherence, inhaler technique, environmental triggers, and comorbid conditions—only then should you escalate treatment by 1-2 steps and reassess in 2 weeks. 1
Step 1: Assess Level of Control
Determine if asthma is "not well controlled" or "very poorly controlled" using these specific criteria 1:
Not Well Controlled:
- Symptoms >2 days/week 1
- Nighttime awakenings 1-3x/week 1
- Some limitation of normal activity 1
- Short-acting β-agonist use >2 days/week 1
- FEV1 or peak flow 60-80% predicted 1
Very Poorly Controlled:
- Symptoms throughout the day 1
- Nighttime awakenings ≥4x/week 1
- Extremely limited activity 1
- Short-acting β-agonist use several times daily 1
- FEV1 or peak flow <60% predicted 1
Critical caveat: Patients with ≥2 exacerbations requiring oral corticosteroids in the past year should be considered "not well controlled" regardless of symptom scores. 1
Step 2: Identify and Address Modifiable Factors BEFORE Stepping Up
This is where most clinicians fail—you must systematically evaluate these factors before adding medications 1:
Medication Issues:
- Adherence: 40-50% of patients underuse prescribed medications due to concerns about long-term inhaled corticosteroid adverse effects 1
- Inhaler technique: At least 50% of patients do not use inhalers correctly 1
- Device appropriateness: Switch to spacer device or dry powder inhaler if metered-dose inhaler technique is inadequate 1
Environmental Triggers:
- Allergens (house dust mite, pets, pollens) 1
- Occupational exposures—specifically ask if symptoms improve on weekends/holidays 1
- Tobacco smoke (active or passive) 1
Comorbidities:
Medication Interactions:
Step 3: Stepwise Pharmacologic Escalation
For patients not well controlled, step up 1 step; for very poorly controlled, step up 1-2 steps 1:
Step 2: Low-dose inhaled corticosteroids (preferred) OR leukotriene modifiers 1
Step 3: Low-to-medium dose inhaled corticosteroids PLUS long-acting β-agonist (preferred) OR medium-dose inhaled corticosteroids alone 1
Step 4: Medium-to-high dose inhaled corticosteroids PLUS long-acting β-agonist 1
Step 5: High-dose inhaled corticosteroids PLUS long-acting β-agonist PLUS consider omalizumab 1
Step 6: High-dose inhaled corticosteroids PLUS long-acting β-agonist PLUS oral corticosteroids 1
Inhaled corticosteroids are the fundamental first-line controller therapy because they improve asthma control more effectively than any other single medication in both children and adults. 1
Step 4: Reassess in 2 Weeks
After stepping up therapy, re-evaluate control in 2 weeks 1. If still uncontrolled, verify adherence and technique again before further escalation 1.
Step 5: Specialist Referral Criteria
Refer to pulmonology/allergy when 1:
- Difficulty achieving or maintaining control despite optimization 1
- ≥2 bursts of oral corticosteroids in 1 year 1
- Any hospitalization for asthma 1
- Step 4 or higher care required 1
- Considering immunotherapy or biologics 1
Step 6: Acute Exacerbations
For acute worsening, give prednisolone 30-40 mg daily until lung function returns to baseline (typically 7 days, up to 21 days if needed) 1. Short courses do not require tapering 1. Provide short-acting β-agonist via nebulizer or large-volume spacer 1.
Essential Ongoing Management
All patients require 1:
- Written asthma action plan detailing medications and when to escalate 1
- Planned follow-up visits every 2-6 months for those on controller therapy 1
- Use of spacers with all metered-dose inhalers for enhanced drug distribution 1
Common pitfall: Patients and physicians both underestimate symptom severity—39-70% of patients with moderate symptoms believe their asthma is well controlled 1. Use objective criteria, not patient perception alone.