What is the recommended treatment approach for asthma?

Asthma Treatment Approach

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma, with treatment intensity determined by a stepwise approach based on asthma severity and control. 1, 2

Initial Treatment Selection by Severity

Intermittent Asthma

• Short-acting beta2-agonist (SABA) as needed only - no daily controller medication required 1, 2
• SABA use more than twice weekly indicates inadequate control and need to step up to persistent asthma treatment 2

Mild Persistent Asthma (Step 2)

• Low-dose ICS is the preferred treatment (fluticasone propionate 100-250 mcg/day or equivalent) 1, 2
• Alternative options include cromolyn, leukotriene receptor antagonists, nedocromil, or theophylline, though these are less effective 1
• Low-dose ICS reduces severe exacerbations by approximately 50% even in patients with minimal symptoms 3, 4

Moderate Persistent Asthma (Step 3)

• Preferred: Low-dose ICS plus long-acting beta2-agonist (LABA) 1, 2
• Alternative: Medium-dose ICS monotherapy 1
• Second alternative: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1
• Critical warning: LABAs must never be used as monotherapy - always combined with ICS due to increased risk of severe asthma-related events 1, 5

Severe Persistent Asthma (Steps 4-6)

Step 4:

• Medium-dose ICS plus LABA (preferred) 1
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist or theophylline 1

Step 5:

• High-dose ICS plus LABA 1
• Consider adding omalizumab for patients with documented allergies 1

Step 6:

• High-dose ICS plus LABA plus oral corticosteroids 1
• Consider omalizumab for allergic patients 1

Key Dosing Principles

The dose achieving 80-90% of maximum ICS benefit is 200-250 mcg fluticasone propionate equivalent daily - higher doses provide minimal additional efficacy but significantly increase systemic adverse effects 6. Starting with low-dose ICS is appropriate for most patients, as high starting doses show no additional clinical benefit in 3 of 4 efficacy parameters compared to low or moderate doses 7.

Monitoring and Adjustment Algorithm

Assess control every 2-6 weeks initially, then every 3 months once stable 1:

• Well controlled for ≥3 months: Consider stepping down treatment 1
• Not well controlled: Step up one level after verifying proper inhaler technique, medication adherence, and environmental control 1
• Very poorly controlled: Step up 1-2 levels and consider short course of oral corticosteroids 1

Red Flags Indicating Poor Control

• SABA use >2 days/week (excluding exercise prophylaxis) 1, 2
• Nighttime awakenings ≥2 times/month 1
• Any interference with normal activities 1
• Peak expiratory flow <80% predicted or personal best 1

Acute Exacerbation Management

For acute severe asthma (cannot complete sentences, pulse >110, respirations >25, PEF <50% predicted):

• Oxygen 40-60% immediately 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
• Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1, 2
• Add ipratropium 0.5 mg nebulized if life-threatening features present 1
• Consider IV aminophylline 250 mg over 20 minutes for life-threatening cases 1

Criteria for hospital admission: Any life-threatening features, PEF <33% after initial treatment, or afternoon/evening presentation with recent nocturnal symptoms 1

Special Considerations

Adjunctive Therapies

• Subcutaneous allergen immunotherapy: Consider at Steps 2-4 for patients with persistent allergic asthma, though evidence is stronger in children than adults 1, 2
• Leukotriene receptor antagonists: Viable non-steroid alternative for patients who cannot use ICS (e.g., increased intraocular pressure) 2

Safety Monitoring

• Rinse mouth after ICS use to reduce oral candidiasis risk 1, 5
• Monitor growth in pediatric patients - ICS may cause approximately 1 cm reduction in first year, but this effect is not progressive 1
• Consider bone densitometry and ophthalmologic examination with prolonged high-dose ICS use (>1 year) 1
• LABA daily dose should not exceed salmeterol 100 mcg or formoterol 24 mcg 1

Comorbidity Management

• Treat allergic rhinitis, sinusitis, and gastroesophageal reflux as these worsen asthma control 2
• Annual influenza vaccination for all patients with persistent asthma 2

Common Pitfalls to Avoid

• Never start LABA without concurrent ICS - this increases mortality risk 1, 5
• Do not use ICS/LABA combinations for acute symptom relief - these are maintenance medications only 1, 5
• Avoid starting with high-dose ICS - low doses provide equivalent control with fewer adverse effects 7, 6
• Do not ignore patients with infrequent symptoms - even those with symptoms ≤2 days/week benefit from ICS for exacerbation prevention and lung function preservation 3, 4
• Before stepping up therapy, always verify proper inhaler technique, medication adherence, and environmental trigger control 1