What is the first line treatment for asthma symptoms?

First-Line Treatment for Asthma Symptoms

Inhaled short-acting beta-2 agonists (such as salbutamol or albuterol) are the first-line treatment for acute asthma symptoms, while inhaled corticosteroids are the first-line controller medication for persistent asthma requiring daily management. 1

Acute Symptom Relief

For immediate relief of asthma symptoms, the treatment approach depends on severity:

Mild to Moderate Symptoms

• Administer inhaled short-acting beta-2 agonists (salbutamol 5 mg or terbutaline 10 mg via nebulizer, or 2 puffs via metered-dose inhaler with spacer repeated 10-20 times) 1
• Monitor response 15-30 minutes after administration 1
• If peak expiratory flow (PEF) improves to >50% predicted/best, continue with step-up of usual controller therapy 1

Severe or Life-Threatening Symptoms

If the patient cannot complete sentences, has respiratory rate >25/min, pulse >110/min, or PEF <50% predicted:

• Immediately give high-dose inhaled beta-2 agonists (nebulized with oxygen if available) 1
• Add systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• Add ipratropium 0.5 mg nebulized if life-threatening features present 1
• Consider IV aminophylline (250 mg over 20 minutes) or parenteral beta-agonists for life-threatening attacks 1

Long-Term Controller Therapy

For patients with persistent asthma (symptoms >2 days/week or nighttime awakenings >2x/month):

Initial Controller Medication

• Inhaled corticosteroids (ICS) are the most consistently effective first-line controller medication for all severities of persistent asthma 1, 2
• ICS improve asthma control more effectively than any other single long-term medication, including leukotriene receptor antagonists 1
• Starting doses for adults: low-dose ICS (fluticasone 100-250 mcg twice daily equivalent) for mild persistent asthma 1, 3

When ICS Alone Is Insufficient

If symptoms persist despite ICS therapy:

• Adding a long-acting beta-2 agonist (LABA) to ICS is superior to doubling the ICS dose 1, 4
• Combination ICS/LABA (such as fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily) provides greater symptom control and improved peak flow compared to higher-dose ICS monotherapy 5, 4, 6, 7
• For patients ≥12 years, adding LABA is preferred over adding leukotriene receptor antagonists 1

Alternative Options

• Leukotriene receptor antagonists are an alternative (but not preferred) option for mild persistent asthma when ICS cannot be used 1
• They can be added as adjunctive therapy if response to ICS remains incomplete 1

Critical Pitfalls to Avoid

• Never use LABA monotherapy without ICS - this increases risk of serious asthma-related events and death 5
• Do not use sedation in acute asthma - it is contraindicated 1
• Antibiotics are unhelpful unless bacterial infection is documented 1
• Increasing use of short-acting beta-agonists (>2 days/week for symptom relief) indicates inadequate control and need for controller therapy intensification 1
• Do not delay systemic corticosteroids in severe exacerbations - underuse of corticosteroids contributes to preventable asthma deaths 1

Monitoring Response

• Assess peak expiratory flow 15-30 minutes after initial treatment 1
• Patients requiring hospital admission should not be discharged until PEF >75% predicted/best with diurnal variability <25% and no nocturnal symptoms 1
• For cough-variant asthma specifically, ICS should be considered first-line with step-up if response is incomplete 1