First-Line Medication for Asthma
Inhaled corticosteroids (ICS) are the first-line controller medication for all patients with persistent asthma, as they are the most consistently effective long-term control medication at all steps of care and superior to any other single agent in improving asthma control, reducing exacerbations, and decreasing mortality risk. 1, 2, 3, 4
Classification Determines Treatment Initiation
Before prescribing, you must distinguish between intermittent and persistent asthma:
Intermittent asthma (symptoms ≤2 days/week, nighttime awakenings ≤2 times/month): No daily controller medication needed—use short-acting beta-agonist (SABA) as needed only 1, 3, 4
Persistent asthma (symptoms >2 days/week OR nighttime awakenings >2 times/month OR SABA use >2 times/week excluding exercise): Requires daily ICS as first-line controller 2, 3, 4
Why ICS Are First-Line
The evidence supporting ICS as first-line therapy is exceptionally strong:
- ICS improve asthma control more effectively than leukotriene receptor antagonists (LTRAs) or any other single long-term control medication in both children and adults 1
- ICS are the only currently available therapy that suppresses the underlying inflammation characteristic of asthma 5
- ICS reduce impairment, prevent exacerbations, and may reduce asthma mortality 1, 5
- The dose-response curve for ICS is relatively flat—high doses provide minimal additional benefit over moderate doses but increase systemic side effects 2
Specific First-Line Regimen
For mild persistent asthma (Step 2 care):
- Low-dose ICS daily is the preferred treatment 1, 3, 4
- Alternative (but not preferred) options include LTRAs, cromolyn, or nedocromil 1
When ICS Alone Is Insufficient
If symptoms remain uncontrolled on low-dose ICS:
- Add a long-acting beta-agonist (LABA) to low-dose ICS rather than increasing ICS dose 2, 4, 5
- For patients ≥12 years, adding LABA is preferred over increasing ICS dose alone 4
- Alternatively, consider adding LTRA after reconsideration of alternative causes 1
Critical Safety Warning
Never use LABA as monotherapy without concurrent ICS—this significantly increases risk of asthma exacerbations and death 2, 4
Special Consideration for Chronic Cough
For patients presenting with chronic cough as the primary or sole manifestation of asthma (cough variant asthma):
- ICS should be considered first-line treatment 1
- If response is incomplete, step up ICS dose and consider adding LTRA 1
Common Pitfall to Avoid
Do not confuse intermittent with persistent asthma—patients using SABA more than twice weekly (excluding exercise prophylaxis) have persistent asthma and need controller therapy with ICS, not just as-needed SABA 2, 4. Using more than one SABA canister per month indicates inadequate control and need for ICS initiation or intensification 1.