What is the recommended treatment for bronchial asthma?

Treatment of Bronchial Asthma

Inhaled corticosteroids are the most effective and preferred first-line controller medication for all patients with persistent asthma, regardless of age or severity. 1, 2

Long-Term Controller Therapy

First-Line Treatment: Inhaled Corticosteroids (ICS)

• ICS improve asthma symptoms more effectively than any other single long-term control medication, demonstrating superior outcomes in symptom scores, exacerbation rates, reduced hospitalizations, and decreased need for oral corticosteroids compared to all other controller options. 1, 2

• ICS work by suppressing airway inflammation through multiple mechanisms, controlling symptoms and preventing exacerbations in most patients with persistent asthma. 3, 4

• Start with low-dose ICS for mild persistent asthma, taken twice daily. 2, 5

• No clinically meaningful differences exist among various ICS formulations; metered-dose inhalers with spacers increase lung deposition from 20-30% to significantly higher levels. 1

Alternative First-Line Options (Not Preferred)

• Leukotriene receptor antagonists (LTRAs) are an alternative but not preferred treatment for mild persistent asthma (Step 2 care), particularly when patient circumstances warrant oral rather than inhaled therapy. 1

• LTRAs (montelukast for ages ≥2 years, zafirlukast for ages ≥7 years) may offer better compliance due to oral administration but are less effective than ICS. 1

• Cromolyn and nedocromil are no longer recommended as initial therapy due to inferior efficacy compared to ICS. 1

Step-Up Therapy for Inadequate Control

When to Intensify Treatment

• Using short-acting beta2-agonists more than two days per week (excluding exercise prevention) or more than two nights per month indicates inadequate control and requires initiation or intensification of anti-inflammatory therapy. 1, 5

Adding Long-Acting Beta2-Agonists (LABAs)

• For patients ≥12 years with asthma inadequately controlled on ICS alone, adding a LABA is the preferred adjunctive therapy over increasing ICS dose or adding LTRAs. 1, 2

• LABAs must NEVER be used as monotherapy for asthma—this increases risk of asthma exacerbations and death. 1, 2, 6

• LABAs should only be prescribed in combination with ICS, preferably as a single combination inhaler (e.g., fluticasone/salmeterol) to ensure compliance. 6

Alternative Step-Up Options

• Increasing the ICS dose should be given equal weight to adding LABAs when stepping up therapy. 1

• LTRAs can be added to ICS as combination therapy for moderate persistent asthma, though they are not the preferred adjunctive agent in patients ≥12 years compared to LABAs. 1

Acute Exacerbation Management

Moderate to Severe Exacerbations

• Oral systemic corticosteroids (prednisolone 1-2 mg/kg/day for 3-10 days in children [max 40 mg/day], or 40-60 mg/day in adults for 5-10 days) are recommended for moderate to severe asthma exacerbations. 1, 5

• Tapering is not necessary after short courses. 1

Acute Symptom Relief

• Inhaled short-acting beta2-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms. 1

• Nebulized bronchodilators (salbutamol 5 mg or terbutaline 10 mg) should be administered with oxygen as the driving gas whenever possible in acute severe asthma. 1

• For severe exacerbations, add nebulized ipratropium 250-500 mcg to beta2-agonist therapy. 1

Stepwise Treatment Algorithm

Intermittent Asthma

• Short-acting beta2-agonist as needed only; no daily controller medication required. 5, 7

Mild Persistent Asthma (Step 2)

• Low-dose ICS twice daily as preferred treatment. 2, 5, 7
• Alternative: LTRA (if oral administration strongly preferred). 1, 7

Moderate Persistent Asthma (Step 3)

• Low to medium-dose ICS plus LABA as preferred combination. 5, 7
• Alternative: Increase ICS to medium dose, or add LTRA to low-dose ICS. 7

Severe Persistent Asthma (Step 4+)

• High-dose ICS plus LABA. 5
• Consider additional controllers or referral to specialist. 5

Critical Pitfalls to Avoid

• Never prescribe LABAs without concurrent ICS—this is associated with increased asthma mortality. 1, 6

• Do not use ICS for acute symptom relief; they have delayed onset of action and are insufficient for exacerbations. 1

• Ensure proper inhaler technique with spacers for metered-dose inhalers to maximize drug delivery. 1, 2

• Do not combine LABAs from different sources (e.g., separate LABA inhaler plus combination ICS/LABA) due to overdose risk. 6

Monitoring and Follow-Up

• Assess asthma control at each visit using symptom frequency, nighttime awakenings, SABA use, and activity limitation. 2, 5

• Step down therapy when asthma is well-controlled for at least 3 months to find the minimum effective dose. 7

• Monitor for local side effects: oral candidiasis (rinse mouth after ICS use), dysphonia, and cough. 1, 6

• Long-term ICS use requires monitoring for systemic effects including bone mineral density, growth in children, and ocular complications (cataracts, glaucoma). 6