Typical Treatment Plan for Asthma
Inhaled corticosteroids (ICS) are the cornerstone of treatment for all patients with persistent asthma and should be taken daily on a long-term basis, as they are the most effective anti-inflammatory medication available and improve asthma control more effectively than any other single long-term control medication. 1
Stepwise Treatment Approach Based on Severity
Mild Intermittent Asthma
- As-needed short-acting beta2-agonists (SABA) alone for symptom relief (e.g., albuterol/salbutamol) 2, 3
- No daily controller medication required 1
- Patients should receive proper inhaler technique instruction 3
Mild Persistent Asthma
- Low-dose inhaled corticosteroids as the preferred first-line controller medication 1, 2
- Alternative second-line options include leukotriene receptor antagonists (montelukast), which offer easier use and high compliance rates 1
- Plus as-needed SABA for symptom relief 2
Moderate Persistent Asthma
- Low-dose ICS plus long-acting beta2-agonist (LABA) combination therapy is preferred 2
- Alternative: Medium-dose ICS monotherapy 2
- Alternative: Low-dose ICS plus leukotriene receptor antagonist 2
- Plus as-needed SABA 1
Severe Persistent Asthma
- High-dose ICS plus LABA combination therapy 1, 2
- Consider adding oral corticosteroids if needed 2
- Consider omalizumab for patients with allergic asthma 2
- Plus as-needed SABA 1
Key Medication Principles
Controller Medications (Daily Use)
- Inhaled corticosteroids suppress inflammation in asthmatic airways and inhibit almost every aspect of the inflammatory process 4
- Combination ICS/LABA therapy (e.g., fluticasone/salmeterol) provides greater asthma control than increasing ICS dose alone and is more effective than adding leukotriene modifiers 5, 6
- For patients ≥12 years, adding LABA to ICS is preferred over adding leukotriene receptor antagonists 1
- The dose-response curve for ICS is relatively flat; adding another medication class is often preferable to increasing ICS dose 4
Rescue Medications (As-Needed)
- Short-acting beta2-agonists are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of symptoms 1
- Critical warning sign: Using SABA more than 2 days per week (excluding exercise-induced use) or more than 2 nights per month indicates inadequate asthma control and need to intensify anti-inflammatory therapy 1
- If using more than one SABA canister per month, daily controller therapy must be increased 1
Acute Exacerbation Management
Mild Exacerbations (PEF >50% predicted, can speak in sentences)
- Nebulized salbutamol 5 mg or terbutaline 10 mg 1, 3
- Monitor response at 15-30 minutes 1
- If PEF remains 50-75% predicted after bronchodilator: add prednisolone 30-60 mg orally 1, 3
- Follow-up within 48 hours 3
Severe Exacerbations (PEF <50% predicted, cannot complete sentences, pulse >110, respiratory rate >25)
- Oxygen 40-60% immediately 1, 3
- Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas 1, 3
- Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg immediately 1, 3
- Add ipratropium to nebulizer if inadequate response 1
- Strongly consider hospital admission if any severe features persist after initial treatment 1
- Follow-up within 24 hours 3
Life-Threatening Features Requiring ICU Transfer
- Deteriorating PEF, worsening exhaustion, feeble respirations 1
- Persistent hypoxia or hypercapnia 1
- Confusion, drowsiness, coma, or respiratory arrest 1
Essential Self-Management Components
Every patient must receive 1, 2, 3:
- Written asthma action plan with pre-arranged steps based on symptoms/peak flow
- Understanding of "relievers" (bronchodilators) versus "preventers" (anti-inflammatory medications)
- Peak flow meter with instruction on proper use
- Clear instructions for when to seek urgent medical attention
- Regular monitoring of symptoms and peak flow on a chart
Critical Pitfalls to Avoid
- Underuse of corticosteroids is a major preventable factor in asthma deaths 1, 3
- Overreliance on bronchodilators without anti-inflammatory treatment leads to poor outcomes 3
- Underestimating severity of exacerbations—delay can be fatal 1, 2
- Delayed administration of systemic corticosteroids during severe exacerbations 2, 3
- Never use LABA monotherapy without ICS, as this increases risk of serious asthma-related events 7
- Do not combine multiple LABA-containing products due to overdose risk 7
Monitoring and Follow-Up
Regular Monitoring
- Assess symptom control, nighttime awakenings, SABA use frequency, and interference with activities 2
- Objective lung function testing with FEV1 or PEF (goal ≥80% predicted or personal best) 2
- Review inhaler technique at every visit 2, 3
- Monitor for oral candidiasis—advise rinsing mouth with water after ICS use 7
- Assess bone mineral density periodically with long-term ICS use 2, 3
- Monitor growth in pediatric patients 7
Step-Down Therapy
- Consider reducing treatment when asthma has been stable for at least 3 months 2
- Use the lowest effective dose to minimize side effects 1, 3