What is the recommended approach for asthma management?

Asthma Management

Asthma management requires a stepwise approach centered on inhaled corticosteroids (ICS) as the foundation of long-term control therapy, with treatment intensity adjusted based on disease severity and control status, while short-acting beta-agonists (SABAs) alone without ICS are no longer recommended as monotherapy. 1, 2

Core Components of Asthma Care

Effective asthma management incorporates four essential components that must be addressed at every clinical encounter 1:

• Assessment and monitoring of asthma severity and control using both impairment (current symptoms, functional limitations) and risk domains (future exacerbations, lung function decline) 1
• Patient education including proper inhaler technique, written asthma action plans, and recognition of worsening symptoms 1
• Environmental control measures to reduce exposure to allergens and irritants, with particular emphasis on tobacco smoke avoidance 1
• Medication management using a stepwise approach with ICS-based controllers 1

Assessment of Asthma Severity and Control

Classification of Severity (for initiating therapy)

Asthma severity should be classified based on specific clinical parameters before starting long-term control therapy 1:

• Intermittent: Symptoms <2 days/week, nighttime awakenings <2x/month, SABA use ≤2 days/week, no interference with normal activity 1
• Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month 1
• Moderate Persistent: Daily symptoms, nighttime awakenings >1x/week but not nightly, daily SABA use, some limitation of normal activity 1
• Severe Persistent: Symptoms throughout the day, nighttime awakenings often 7x/week, SABA use several times per day, extremely limited activity 1

Monitoring Control (for adjusting therapy)

Once treatment is initiated, regularly assess control to determine whether to step up or step down therapy 1:

• Symptom frequency and intensity over the previous 2-4 weeks 1
• SABA use for quick relief (not for exercise-induced bronchospasm prevention) 1
• Peak expiratory flow (PEF) measurements, particularly in patients with moderate-severe asthma or history of severe exacerbations 1
• Frequency of exacerbations requiring urgent care, hospitalization, or ICU admission 1
• Pulmonary function testing with spirometry when available 1

Stepwise Pharmacological Management

General Principles

Inhaled corticosteroids are the most effective long-term control therapy and should be initiated as soon as possible in patients with persistent asthma. 1, 2, 3

The stepwise approach involves 1:

• Stepping up therapy if asthma is not well controlled (after verifying proper inhaler technique, medication adherence, and environmental control) 1
• Stepping down therapy if asthma has been well controlled for at least 3 months 1
• Avoiding SABA monotherapy without concurrent ICS use, as this is no longer recommended 2

Medication Selection by Step

Step 1-2 (Mild Asthma):

• Initiate low-dose ICS as the preferred controller medication 1
• Consider ICS-formoterol as needed for both maintenance and reliever therapy (MART approach) in adults and adolescents, which reduces severe exacerbations 2, 4
• Alternative: Leukotriene receptor antagonists if ICS cannot be used 1

Step 3 (Moderate Asthma):

• Increase to medium-dose ICS, OR add long-acting beta-agonist (LABA) to low-dose ICS 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
• Consider specialist consultation at this step 1

Step 4-5 (Severe Asthma):

• Medium-to-high dose ICS plus LABA 1
• Consider adding long-acting muscarinic antagonists, leukotriene receptor antagonists, or theophylline before advancing to Step 5 2
• Refer to asthma specialist for consideration of add-on treatments 1

Step 5-6 (Severe Uncontrolled Asthma):

• High-dose ICS plus LABA plus additional controller 1
• Consider phenotype-specific biologic agents (omalizumab for allergic asthma, anti-IL-5 agents for eosinophilic asthma) 2, 4
• Oral corticosteroids may be necessary but should be minimized due to systemic effects 1
• Mandatory specialist referral 1

Reliever Medications

• Preferred: Short-acting beta-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized, or 2-4 puffs via metered-dose inhaler with spacer) 1, 4
• Alternative approach: ICS-formoterol as both controller and reliever (MART strategy) for adults and adolescents, which is preferred due to superior reduction in severe exacerbations 2, 4
• Frequent SABA use (>2 days/week) indicates need to step up long-term controller therapy 1

Special Considerations

Allergen Immunotherapy

• Consider subcutaneous allergen immunotherapy in Steps 2-4 for patients with persistent allergic asthma when clear relationship exists between symptoms and allergen exposure 1
• Must be administered by personnel prepared to treat anaphylaxis 1
• Sublingual immunotherapy is not recommended 4

Comorbid Conditions

Recognize and treat conditions that complicate asthma control 1:

• Allergic rhinitis and sinusitis 1
• Gastroesophageal reflux disease (GERD) 1
• Obstructive sleep apnea (OSA) 1
• Obesity 1
• Vocal cord dysfunction (can mimic asthma; diagnose via laryngoscopy during episode) 1
• Allergic bronchopulmonary aspergillosis 1

Systemic Corticosteroid Considerations

When transitioning patients from oral corticosteroids to ICS 5:

• Reduce prednisone by 2.5 mg weekly during ICS therapy 5
• Monitor lung function (FEV1 or morning PEF), beta-agonist use, and symptoms carefully 5
• Observe for adrenal insufficiency signs (fatigue, weakness, nausea, vomiting, hypotension) 5
• Be aware that withdrawal may unmask previously suppressed allergic conditions 5

Drug Interactions

Avoid strong CYP3A4 inhibitors (ritonavir, ketoconazole, itraconazole, clarithromycin) with ICS-containing medications due to increased systemic corticosteroid effects and cardiovascular adverse events 5

Critical Safety Warnings

LABA Black Box Warning

LABAs carry an FDA black box warning for increased risk of severe exacerbations, though uncommon 1:

• Never use LABAs as monotherapy for asthma 1
• Always combine with ICS 1
• Not recommended for acute symptoms or exacerbations 1
• Patients must be instructed not to discontinue ICS when taking LABA 1

Contraindicated Interventions

• Sedatives are absolutely contraindicated in asthmatic patients as they worsen respiratory depression 1, 6
• Antibiotics only if bacterial infection is documented, not for elevated inflammatory markers alone 1, 7
• Percussive physiotherapy is unnecessary in acute asthma 1

Cardiovascular and Hypersensitivity Risks

• Beta-agonists can cause tachycardia (up to 200 bpm), arrhythmias, hypertension, tremor, and QTc prolongation 5
• Use with caution in patients with cardiovascular disorders, especially coronary insufficiency 5
• Immediate hypersensitivity reactions including anaphylaxis can occur with ICS-LABA combinations 5
• Patients with severe milk protein allergy should not use lactose-containing powder inhalers 5

Common Pitfalls to Avoid

• Underestimating severity: Patients and physicians often fail to appreciate asthma severity, leading to delayed treatment escalation 1
• Underuse of corticosteroids: Both inhaled and systemic corticosteroids are frequently underutilized despite being cornerstone therapy 1
• Poor inhaler technique: Always verify proper technique before stepping up therapy 1
• Inadequate environmental control: Single interventions are generally ineffective; multifaceted approaches targeting specific allergen sensitivities are needed 1
• Failure to provide written action plans: All patients should have written instructions for daily management and managing worsening asthma 1
• Delaying specialist referral: Refer when difficulties achieving control, considering omalizumab, or additional testing needed 1

Monitoring and Follow-up

• Regular assessment of control at every visit using validated tools (Asthma Control Test, asthma APGAR) 4
• Peak flow monitoring particularly helpful for patients with difficulty perceiving symptoms, history of severe exacerbations, or moderate-severe asthma 1
• Height and weight monitoring in children on ICS to assess growth velocity 1
• Influenza vaccination annually for all patients over 6 months 1