Escalate Maintenance Therapy Immediately
Using a rescue inhaler two or more times daily signals inadequately controlled asthma and requires immediate intensification of maintenance therapy. 1
Immediate Action Required
The British Thoracic Society guidelines explicitly state that SABA use more than 2-3 times daily is the trigger for increasing treatment at all stages of asthma management. 1 This patient's twice-daily rescue inhaler use indicates their current maintenance regimen is insufficient to control underlying airway inflammation.
Before Escalating Treatment
First verify two critical factors before adding medications: 1
- Check inhaler technique - Improper technique is a common cause of apparent treatment failure 1
- Assess medication compliance - Non-adherence must be addressed before treatment escalation 1
Treatment Escalation Algorithm
The specific escalation depends on what maintenance therapy the patient is currently receiving:
If on Low-Dose Inhaled Corticosteroid (ICS) Alone
Add a long-acting beta-agonist (LABA) to the existing ICS. 1, 2 This combination is more effective than increasing ICS dose alone for moderate persistent asthma. 2
Critical safety warning: Never prescribe LABA as monotherapy - it must always be combined with ICS to avoid increased risk of asthma exacerbations and death. 2, 3
If on ICS Dose Below 800 mcg/day Beclomethasone Equivalent
Increase the ICS dose up to 800 mcg/day equivalent of beclomethasone. 1 If the patient cannot tolerate higher ICS doses, add a non-steroidal anti-inflammatory agent. 1
If Already on ICS + LABA Combination
Increase to high-dose ICS plus LABA. 2 Consider adding additional controller medications such as leukotriene modifiers or long-acting muscarinic antagonists. 2
Key Monitoring Parameters
Document these specific indicators of poor control: 1, 2
- Frequency of SABA use (record as "occasions per day" not "puffs") 1
- Symptom-free days per week 1
- Nighttime awakenings due to asthma 1
- Limitations on daily activities 1
- Peak expiratory flow measurements (if dropping below 60% of patient's best, this signals need for rescue corticosteroids) 1
Common Pitfalls to Avoid
Do not simply continue current therapy and tell the patient to "use rescue inhaler as needed." This approach ignores the underlying inflammation driving symptoms and increases risk of exacerbations. 1, 2
Do not add another LABA-containing medication if the patient is already on a combination inhaler - this creates risk of LABA overdose. 3
Do not assume the patient needs rescue corticosteroids yet - this level of SABA use indicates poor chronic control, not necessarily an acute exacerbation requiring oral prednisone. 1 Reserve oral corticosteroids for when peak flow drops below 60% of best, symptoms worsen day-by-day, or sleep disturbance extends to midday. 1
Follow-Up Timeline
Reassess in 1-3 months after treatment escalation. 1 The patient should demonstrate a period of stability on the new regimen before considering any stepwise reduction. 1 If symptoms improve and SABA use decreases to less than 2-3 times daily with minimal symptoms and no activity limitations, the current regimen is appropriate. 1