What is the recommended treatment approach for asthma?

Treatment for Asthma

Inhaled corticosteroids (ICS) are the most effective first-line controller medication for all patients with persistent asthma, regardless of age or severity, and should be initiated at low-to-medium doses (100-250 mcg fluticasone propionate equivalent daily) as this achieves 80-90% of maximum therapeutic benefit. 1, 2, 3

Stepwise Treatment Algorithm

Step 1: Intermittent Asthma

• Short-acting beta-agonist (SABA) as needed only - no daily controller medication required 2
• Use for symptoms occurring ≤2 days/week with normal lung function between episodes 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose ICS (100-250 mcg fluticasone propionate equivalent daily) 1, 2
• Alternative options: leukotriene receptor antagonist, cromolyn, nedocromil, or theophylline 2
• Continue SABA as needed for symptom relief 2

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS + long-acting beta-agonist (LABA) 1, 2
• Alternative: Medium-dose ICS alone (>250-500 mcg fluticasone propionate equivalent) 2
• Critical warning: Never use LABA as monotherapy - must always be combined with ICS due to increased risk of severe asthma-related events and mortality 1, 4

Step 4-6: Severe Persistent Asthma

• High-dose ICS + LABA (>500 mcg fluticasone propionate equivalent) 1, 2
• Consider adding omalizumab for allergic asthma 2
• May require oral corticosteroids for severe cases 1, 2

Universal Elements at Every Step

• Patient education about disease and self-management 1, 2
• Environmental control measures - identify and avoid triggers including allergens, tobacco smoke 1, 2
• Assess inhaler technique at every visit - improper technique is a major cause of treatment failure 1, 2
• Verify medication adherence before escalating therapy 1, 2
• Evaluate and manage comorbidities (rhinitis, GERD, obesity) 2

When to Step Up or Step Down

Step Up Treatment When:

• Using SABA >2-3 times daily 1
• Nighttime awakenings ≥2x/month 1
• Any limitation in normal activities 1
• FEV1 <80% predicted 1
• Before stepping up: verify adherence, inhaler technique, environmental control, and comorbidities 1, 2

Step Down Treatment When:

• Asthma well-controlled for at least 3 months 1, 2
• Reassess control every 2-6 weeks after adjustment 1

Critical Medication Considerations

Inhaled Corticosteroids

• Most effective at low-to-medium doses - the dose-response curve is relatively flat, with 80-90% of maximum benefit achieved at 200-250 mcg fluticasone propionate equivalent 1, 3, 5
• High doses (>500 mcg) provide minimal additional benefit for most patients but significantly increase risk of systemic side effects 1, 6, 5
• Advise patients to rinse mouth after use to reduce oral candidiasis risk 1
• Use spacer/valved holding chamber with metered-dose inhalers to improve delivery and reduce side effects 1

Long-Acting Beta-Agonists

• FDA Black Box Warning: increases risk of asthma-related death when used as monotherapy 1, 4
• Maximum daily dose: 100 mcg salmeterol or 24 mcg formoterol 1
• Never use for acute symptom relief - only for maintenance therapy 1, 4
• Patients must continue ICS even if symptoms improve significantly 1

Device Selection

• Start with metered-dose inhaler (MDI) 1
• Add spacer/valved holding chamber if coordination difficulties 1
• Dry powder inhalers require rapid inhalation (≥60 L/min) - ineffective in children <4 years 1

Acute Exacerbation Management

Immediate Treatment

• High-dose inhaled beta-agonist (salbutamol 5 mg or terbutaline 10 mg nebulized, or 10-20 puffs via spacer) 1
• Systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• Continue for 7-21 days until lung function returns to baseline - no taper needed for courses <2 weeks 1

Life-Threatening Features Requiring Additional Treatment

• Add ipratropium 0.5 mg nebulized 1
• Consider IV aminophylline 250 mg over 20 minutes (avoid if already on oral theophylline) 1
• Oxygen to maintain saturation 1

Hospital Admission Criteria

• Peak flow <33% predicted after initial treatment 1
• Life-threatening features: silent chest, cyanosis, exhaustion, altered consciousness 1
• Persistent severe symptoms despite treatment 1

Common Pitfalls to Avoid

• Do not rely on symptoms alone - assess both impairment and exacerbation risk 1, 2
• Do not prescribe LABA without ICS - this increases mortality risk 1, 4
• Do not automatically increase ICS dose - verify adherence and technique first, then consider adding LABA rather than doubling ICS 1, 2
• Do not use antibiotics routinely - only if bacterial infection confirmed 1
• Do not sedate patients during acute exacerbations - contraindicated 1
• Do not use high-dose ICS as initial therapy - start at low-medium doses for optimal benefit-risk ratio 6, 5

Additional Considerations

• Annual influenza vaccination for all patients with persistent asthma 2
• Monitor growth in children on ICS - effect is small (~1 cm) and non-progressive 1
• Consider bone density monitoring and calcium/vitamin D supplementation with prolonged high-dose ICS use 1
• Allergen immunotherapy may be considered for allergic asthma at steps 2-4 1