Best Maintenance Therapy for Asthma Exacerbations in Teenagers
For teenagers aged 12 years and older experiencing asthma exacerbations, the best maintenance therapy is ICS-formoterol (inhaled corticosteroid-formoterol) in a single inhaler used as both daily controller and reliever therapy, which provides superior exacerbation prevention compared to higher-dose ICS alone or same-dose ICS-LABA with separate SABA rescue therapy. 1
Primary Maintenance Strategy
ICS-Formoterol Single Inhaler (SMART Therapy)
The 2020 NAEPP guidelines provide a strong recommendation with high-quality evidence for ICS-formoterol in a single inhaler as both daily controller and reliever therapy in individuals aged 12 years and older with moderate to severe persistent asthma. 1 This approach is superior to:
- Higher-dose ICS as daily controller with SABA for quick-relief 1
- Same-dose ICS-LABA as daily controller with SABA for quick-relief 1
This strategy allows teenagers to adjust their ICS intake in response to symptom fluctuation, which is particularly important given that airway inflammation varies over time with exposures such as viral infections and allergens. 2
Alternative Maintenance Options by Severity
For Mild Persistent Asthma (Ages 12+)
Two conditionally recommended options exist with moderate-quality evidence: 1
Daily low-dose ICS plus as-needed SABA for quick-relief - This remains the traditional approach and is effective when adherence is maintained 1
As-needed ICS and SABA used concomitantly - This strategy addresses the poor adherence problem common in teenagers, as many patients overuse short-acting beta2-agonist relievers while neglecting daily maintenance therapy 2
For Moderate to Severe Persistent Asthma
If ICS-formoterol single inhaler is not available or appropriate, the combination of ICS plus long-acting beta agonist (LABA) leads to clinically meaningful improvements in lung function, symptoms, and reduced need for quick-relief medications. 1 This combination is strongly supported by evidence in patients 12 years and older. 1
Adding LAMA (long-acting muscarinic antagonist) to ICS-LABA is conditionally recommended with moderate-quality evidence for teenagers with uncontrolled persistent asthma despite ICS-LABA therapy. 1
Important Dosing Considerations
ICS Dose Strategy
Do NOT routinely increase ICS doses during exacerbations in teenagers aged 4 years and older with mild to moderate persistent asthma who are adherent to daily ICS treatment. 1 This conditional recommendation is based on low-quality evidence showing that short-term increases in ICS dose for increased symptoms or decreased peak flow do not provide significant benefit. 1, 3
The standard daily dose of ICS should be 200-250 μg of fluticasone propionate or equivalent, which achieves 80-90% of the maximum obtainable benefit. 4 Higher doses are associated with significant risk of systemic adverse effects without proportional therapeutic gain. 4
Quick-Relief Therapy
Short-acting beta2-agonists (albuterol) remain the most effective therapy for rapid reversal of airflow obstruction and prompt relief of asthmatic symptoms, with onset of action within 5 minutes. 1
Critical warning sign: Using short-acting beta2-agonists more than two days per week for symptom relief (not for prevention of exercise-induced bronchospasm) indicates inadequate asthma control and the need to intensify anti-inflammatory therapy. 1
Management of Acute Exacerbations
For moderate to severe exacerbations, oral systemic corticosteroids are significantly more effective than inhaled corticosteroids in preventing hospitalizations and improving lung function. 5 Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) should be used during acute exacerbations. 1
High-dose inhaled corticosteroids started early provide only modest benefit in mild exacerbations and should not be used routinely to treat acute exacerbations. 5
Common Pitfalls to Avoid
Adherence is the primary barrier to effective asthma control in teenagers. 2 Poor adherence to ICS-containing medications as daily maintenance therapy is associated with increased risk of severe exacerbations and death. 2 The as-needed ICS strategies (particularly ICS-formoterol single inhaler) address this by empowering patients to adjust their ICS intake in response to symptoms. 2
Avoid prescribing leukotriene receptor antagonists (LTRAs) as first-line add-on therapy in teenagers 12 years and older with uncontrolled persistent asthma. 1 The guidelines conditionally recommend against adding LAMA to ICS compared to adding LABA to ICS with moderate-quality evidence. 1 LTRAs are alternative, second-line options that can provide good symptom control but are not preferred over LABA addition. 1
Do not use oral short-acting beta2-agonists - they are less potent, take longer to act, and have more side effects compared with inhaled formulations. 1
Monitoring and Follow-Up
After discharge from an acute exacerbation, teenagers should have: 1
- Been on discharge medication for 24 hours with inhaler technique checked and recorded 1
- Peak expiratory flow >75% of predicted or best with diurnal variability <25% 1
- Treatment with oral steroids, inhaled steroids, and bronchodilators 1
- Written self-management plan 1
- Follow-up within 1 week and clinic appointment within 4 weeks 1