Asthma: Comprehensive Overview and Treatment
What is Asthma?
Asthma is a chronic inflammatory disease of the airways characterized by reversible airflow obstruction, airway hyperresponsiveness, and underlying inflammation involving mast cells, eosinophils, and other inflammatory mediators. 1
Core Treatment Principles
Inhaled corticosteroids (ICS) are the most effective and preferred first-line controller medication for all patients with persistent asthma, regardless of age or severity. 2, 3 ICS work by suppressing airway inflammation through multiple mechanisms, including reversing histone acetylation and switching off activated inflammatory genes. 4
Key Treatment Algorithm
Every patient requires assessment at each visit, with treatment adjusted based on a stepwise approach. 2 All patients need patient education, environmental control measures, and management of comorbidities at every step. 2
Stepwise Treatment Approach
Step 1: Intermittent Asthma
- Preferred: Short-acting beta-agonist (SABA) as needed only 2, 5
- No daily controller medication required 3
Step 2: Mild Persistent Asthma
- Preferred: Low-dose inhaled corticosteroid 2, 3
- Alternative options: Leukotriene receptor antagonists (montelukast or zafirlukast), cromolyn, nedocromil, or theophylline 2, 6
- Leukotriene receptor antagonists offer high compliance rates and ease of use but are less effective than ICS 2, 6
Step 3: Moderate Persistent Asthma
- Preferred: Low-dose ICS plus long-acting beta-agonist (LABA) OR medium-dose ICS alone 2, 3
- Alternative: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2
- For patients ≥12 years, adding LABA to low-dose ICS is preferred over increasing ICS dose 2, 5
Step 4: Moderate-to-Severe Persistent Asthma
- Preferred: Medium-dose ICS plus LABA 2, 3
- Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2
Step 5: Severe Persistent Asthma
- Preferred: High-dose ICS plus LABA 2, 3
- Consider adding: Omalizumab (anti-IgE biologic) for patients with documented allergies 2
Step 6: Very Severe Persistent Asthma
- Preferred: High-dose ICS plus LABA plus oral corticosteroid 2
- Consider adding: Omalizumab for allergic patients 2
- Before adding oral steroids, trial of high-dose ICS plus LABA plus leukotriene receptor antagonist may be considered 2
Critical Safety Warnings
Never use long-acting beta-agonists (LABA) as monotherapy for asthma—this increases risk of asthma exacerbations and death. 2, 5 LABA must always be combined with an inhaled corticosteroid. 2
Do not combine LABA-containing medications to avoid overdose risk. 7
Monitoring Treatment Effectiveness
Using SABA more than twice weekly for symptom relief (excluding exercise prevention) or more than two nights monthly indicates inadequate asthma control and requires stepping up anti-inflammatory therapy. 2, 3 This is one of the most important warning signs in clinical practice. 2
Schedule follow-up visits within 2-4 weeks after treatment changes to assess response. 6
Acute Exacerbation Management
For moderate to severe asthma exacerbations, oral systemic corticosteroids are required. 2, 3 High-dose nebulized beta-agonists should be administered, with treatments repeated at 20-minute intervals as needed. 2
Special Populations and Situations
Pediatric Patients (Ages 4-11)
- One inhalation of ICS/LABA 100/50 mcg twice daily for persistent asthma 7
- Monitor growth regularly as ICS may affect bone mineral density 7
Patients with Contraindications to Corticosteroids
- For patients with increased intraocular pressure who cannot use ICS, leukotriene receptor antagonists (montelukast once daily or zafirlukast twice daily) provide a viable non-steroid alternative 6
- These are less effective than ICS but avoid steroid-related complications 6
Allergic Asthma
- Consider subcutaneous allergen immunotherapy for patients with controlled symptoms and documented allergies 2, 3
- Evidence strongest for single allergens including house-dust mites, animal danders, and pollens 2
Exercise-Induced Bronchoconstriction
- Optimize long-term asthma control first 3
- If symptoms persist during exercise despite good control, prescribe specific pre-exercise medications 3
Important Comorbidities to Address
Evaluate and treat conditions that worsen asthma control: 3
- Allergic rhinitis
- Sinusitis
- Gastroesophageal reflux disease
- Medication sensitivities (aspirin, NSAIDs, beta-blockers)
Annual influenza vaccination is recommended for all patients with persistent asthma. 3
Common Pitfalls to Avoid
Do not delay initiating ICS in persistent asthma—early intervention improves outcomes. 5 Patients using SABA more than twice weekly likely need controller therapy, indicating persistent rather than intermittent asthma. 5
Do not initiate ICS/LABA combination therapy during acute deterioration—stabilize first with appropriate acute management. 7
Monitor for oral candidiasis with ICS use. 7 Advise patients to rinse mouth with water and spit after each ICS dose to reduce this risk. 2, 7
Be aware that ICS increase pneumonia risk in COPD patients, though this is less concerning in asthma. 7
Medication Delivery Considerations
Proper inhaler technique is critical for effectiveness. 2 Metered-dose inhalers require slow inhalation (3-5 seconds) followed by 10-second breath-hold, while dry powder inhalers require rapid, deep inhalation. 2
Spacers or valved holding chambers improve lung delivery and reduce oropharyngeal deposition, decreasing local side effects like thrush. 2
Stepping Down Therapy
Once asthma is well-controlled for at least three months, consider stepping down treatment to the lowest effective dose. 2 Always verify adherence, environmental control, and comorbidity management before stepping up therapy. 2
Complementary and Alternative Therapies
Evidence is insufficient to recommend most complementary and alternative treatments including chiropractic therapy, homeopathy, herbal medicine, and breathing techniques. 2 Acupuncture is not recommended for asthma treatment. 2 Always ask patients about all medications and interventions they use, as approximately one-third of patients use alternative methods. 2