What are the guidelines for managing asthma in adults?

Adult Asthma Management Guidelines

Adult asthma management follows a stepwise approach using inhaled corticosteroid (ICS)-based therapy as the foundation, with treatment escalated or de-escalated based on symptom control and exacerbation risk. 1

Core Treatment Principles

Goals of Management

• Abolish symptoms and restore optimal lung function 1
• Minimize exacerbation risk and prevent death 1
• Minimize medication side effects while maintaining control 1
• Enable normal activities without limitations 1

Target Control Metrics

• Minimal to no chronic symptoms, including nocturnal symptoms 1
• Peak expiratory flow (PEF) ≥80% of predicted or personal best 1
• Circadian PEF variation <20% 1
• Minimal need for rescue medications 1

Stepwise Pharmacological Approach

Step 1: Intermittent Asthma

• As-needed short-acting beta-2 agonists (SABAs) alone are no longer recommended as monotherapy 2, 3
• Preferred: As-needed low-dose ICS-formoterol combination 1, 2

Step 2: Mild Persistent Asthma

• Daily low-dose ICS plus as-needed SABA, OR as-needed concomitant ICS and SABA therapy 1, 2
• ICS should be initiated as soon as possible 3

Step 3: Moderate Persistent Asthma

• Low-dose ICS-formoterol as single maintenance and reliever therapy (SMART) is preferred 2
• This approach uses the same inhaler for both daily maintenance and as-needed relief 2
• Alternative: Daily low-dose ICS plus long-acting beta-2 agonist (LABA) with separate SABA for rescue 4

Step 4: Moderate-Severe Persistent Asthma

• Medium-dose ICS-formoterol as SMART therapy 2
• Alternative: Medium-dose ICS-LABA fixed combination with separate SABA 4

Step 5: Severe Persistent Asthma

• Add long-acting muscarinic antagonist (LAMA) to ICS-formoterol therapy 2
• Consider biologic agents for phenotype-specific treatment (severe allergic or eosinophilic asthma) 5, 3
• High-dose ICS-LABA combinations may be needed 1

Critical Management Considerations

Rescue Corticosteroid Courses

Indications for systemic corticosteroids: 1

• PEF falls below 60% of patient's best
• Symptoms progressively worsen day by day
• Sleep disturbed by asthma
• Morning symptoms persist until midday
• Diminishing response to inhaled bronchodilators

Dosing: 6

• Adults: 40-60 mg prednisone daily (or 30-60 mg prednisolone)
• Continue until 2 days after control is established, typically 5-10 days total
• No tapering needed for courses <7-10 days, especially if on inhaled corticosteroids
• Oral administration is equally effective as IV and strongly preferred 6

Acute Severe Asthma Recognition

Features requiring immediate treatment: 1

• Unable to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• PEF <50% predicted or personal best

Life-threatening features: 1

• PEF <33% predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma
• Normal or elevated PaCO2 in a breathless patient

Self-Management Plans

Three essential elements: 1

1. Monitoring symptoms, peak flow, and medication usage
2. Taking prearranged action based on predetermined thresholds
3. Following written guidance

Key self-management actions: 1

• Initiate or increase inhaled corticosteroids when symptoms worsen
• Self-administer oral corticosteroids when PEF falls below agreed threshold or <60% of normal
• Seek urgent medical attention when treatment is not working

Important Pitfalls to Avoid

Medication-Related Errors

• Never use SABA monotherapy without ICS coverage 2, 3
• Do not combine multiple LABA-containing products (risk of overdose) 7
• Do not use short-term ICS dose increases alone for worsening symptoms 2
• Avoid unnecessarily high corticosteroid doses during exacerbations (no additional benefit beyond 40-60 mg prednisone) 6

Assessment Errors

• Do not rely on clinical impression alone; always measure PEF objectively 6
• Recognize that symptom control does not guarantee elimination of exacerbation risk, particularly in severe asthma 1
• Only 70% of patients achieve well-controlled asthma across severity strata with standard therapy 1

Treatment Barriers

• Address inhaler technique and adherence at every visit 1
• Identify and manage comorbidities (GERD, rhinosinusitis, obesity) that contribute to poor control 1
• Consider overlapping disorders presenting with asthma-like symptoms 1
• Evaluate environmental and lifestyle factors requiring specific management 1

Specialist Referral Indications

Refer to respiratory physician for: 1

• Diagnostic uncertainty (elderly, smokers with wheeze)
• Possible occupational asthma
• Continuing symptoms despite high-dose inhaled corticosteroids
• Catastrophic, sudden severe (brittle) asthma
• Consideration for long-term nebulized bronchodilators
• Pregnant women with worsening asthma
• Asthma interfering with lifestyle despite treatment changes
• Recent hospital discharge for asthma

Adjunctive Therapies

Evidence-Based Add-Ons

• Subcutaneous immunotherapy: Recommended as adjunct for patients with symptoms and specific allergen sensitization 2
• Leukotriene receptor antagonists (montelukast): Indicated for prophylaxis and chronic treatment 8, 5
• Allergen mitigation: Only when specific exposure and relevant sensitivity documented; must be allergen-specific with multiple strategies 2

Not Recommended

• Sublingual immunotherapy specifically for asthma 2
• Bronchial thermoplasty as standard care (only within research protocols) 2
• Hyposensitization (immunotherapy) for routine asthma management 1
• Antihistamines including ketotifen 1
• Antibiotics for uncomplicated asthma 1

Monitoring Requirements

• Rinse mouth after ICS use to reduce oral candidiasis risk 7
• Monitor for pneumonia in COPD patients on ICS-LABA 7
• Assess bone mineral density periodically with long-term ICS use 7
• Monitor pediatric growth 7
• Consider ophthalmology referral for long-term ICS users (glaucoma/cataract risk) 7