What is the recommended treatment approach for managing asthma?

Recommended Treatment Approach for Asthma Management

Asthma treatment follows a stepwise approach based on disease severity and control, with inhaled corticosteroids (ICS) forming the foundation of therapy for persistent asthma, combined with long-acting beta-agonists (LABAs) for moderate-to-severe disease, while never using LABAs as monotherapy. 1

Initial Assessment and Classification

Before initiating treatment, classify asthma severity using multiple domains 1:

• Symptom frequency: Intermittent (<2 days/week), mild persistent (>2 days/week but not daily), moderate persistent (daily), or severe persistent (throughout the day) 1
• Nighttime awakenings: <2x/month (intermittent) to often 7x/week (severe) 1
• SABA use for symptom relief: Frequency correlates with severity 1
• Lung function testing: Spirometry or peak expiratory flow (PEF) measurements 1
• Assessment of both impairment (current symptoms and functional limitations) and risk (future exacerbations, lung function decline) 1

Stepwise Pharmacologic Management

Step 1: Intermittent Asthma

• As-needed short-acting β2-agonists (SABAs) only for rescue therapy 2
• No daily controller medication required 1

Step 2: Mild Persistent Asthma

• Preferred: Daily low-dose ICS plus as-needed SABA 2
• Alternative: As-needed concomitant ICS and SABA therapy 2
• This represents a significant update from older guidelines that recommended SABA alone 2

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS-formoterol combination as both daily maintenance and as-needed rescue therapy (single maintenance and reliever therapy, SMART) 2
• Consider specialist consultation at this step 1
• Critical warning: LABAs must never be used as monotherapy; patients must continue ICS even if symptoms improve significantly 1
• Daily LABA use should not exceed 100 mcg salmeterol or 24 mcg formoterol 1

Step 4: Moderate-Severe Persistent Asthma

• Medium-dose ICS-formoterol as both maintenance and reliever therapy 2
• Continue SMART approach with higher ICS dosing 2

Step 5: Severe Persistent Asthma

• Add long-acting muscarinic antagonist (LAMA) such as tiotropium to ICS-formoterol therapy 2, 3
• Consider omalizumab for IgE-mediated asthma 3
• Consider azithromycin for non-eosinophilic asthma 3
• Antibodies against interleukin-5 may be appropriate for severe eosinophilic asthma 3

Step 6: Refractory Severe Asthma

• Assess control and step up if needed, but first verify inhaler technique, adherence, environmental control, and comorbid conditions 1
• Bronchial thermoplasty is not recommended as standard care; use only within research protocols 2

Adjunctive Therapies

Allergen Immunotherapy

• Subcutaneous immunotherapy is recommended as adjunct to pharmacotherapy in steps 2-4 for patients with persistent allergic asthma and documented sensitization 1, 2
• Sublingual immunotherapy is not recommended specifically for asthma 2
• Clinicians administering immunotherapy must be prepared to treat anaphylaxis 1
• The role of allergy is greater in children than adults 1

Fractional Exhaled Nitric Oxide (FeNO)

• Recommended to assist in diagnosis and monitoring, but not as a standalone tool 2
• Helps identify eosinophilic inflammation and predict ICS responsiveness 2

Indoor Allergen Mitigation

• Recommended only when there is documented exposure and relevant sensitivity or symptoms 2
• Must be allergen-specific and include multiple mitigation strategies 2
• Not recommended as universal intervention 2

Monitoring and Adjustment

Regular Assessment

• Evaluate control based on impairment (symptoms over previous 2-4 weeks, SABA use, activity limitations) and risk (exacerbation history, lung function decline) 1
• The level of control is based on the most severe category present 1
• Patients can have adequate symptom control but still be at significant risk of exacerbations; treat accordingly 1

Step-Down Therapy

• Consider stepping down only when asthma is well controlled for at least 3 months 1
• Before stepping down, verify proper inhaler technique, adherence, and environmental control 1

Step-Up Criteria

• Frequent SABA use indicates need to step up treatment 1
• More frequent and intense exacerbations indicate poorer control 1

Critical Warnings and Pitfalls

LABA Black Box Warning

• Never use LABAs as monotherapy for asthma 1, 4
• FDA Black Box warning exists due to increased risk of severe exacerbations, though uncommon, with daily LABA use 1
• Patients must be instructed not to stop ICS therapy while taking LABA 1
• LABAs are not for acute symptom relief or exacerbations 1

What NOT to Do

• Do not recommend short-term increases in ICS dose alone for worsening symptoms 2
• Do not use in combination with additional LABA-containing medications due to overdose risk 4
• Sedation is absolutely contraindicated in acute asthma 1, 5
• Antibiotics only if bacterial infection is clearly present 1, 5
• Percussive physiotherapy is unnecessary 1

Special Populations

Children 0-4 Years

• Diagnosis is challenging due to difficulty obtaining objective measurements 1
• If no clear benefit observed in 4-6 weeks, consider alternative diagnoses 1
• Avoid labels like "wheezy bronchitis" or "reactive airway disease" that delay appropriate asthma treatment 1

Children 5-11 Years

• One inhalation of fluticasone/salmeterol 100/50 twice daily for persistent asthma 4
• Adjust therapy based on control assessment 1

Children ≥12 Years and Adults

• Dosing based on severity: fluticasone/salmeterol 100/50,250/50, or 500/50 twice daily 4
• Starting dosage determined by asthma severity 4

Comorbidity Management

Address conditions that complicate asthma at every step 1:

• Gastroesophageal reflux disease (GERD) 1
• Obstructive sleep apnea (OSA) 1
• Allergic bronchopulmonary aspergillosis 1
• Vocal cord dysfunction (may mimic asthma; diagnose via flow-volume loops or direct visualization) 1

Patient Education Components

Essential at every step 1:

• Proper inhaler technique verification 1
• Peak flow monitoring and interpretation 1
• Written asthma action plan 1
• Environmental trigger avoidance 1
• Recognition of worsening symptoms requiring medical attention 1