What is the typical treatment plan for asthma?

Typical Treatment Plan for Asthma

Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment for all patients with persistent disease, with short-acting beta-agonists reserved for acute symptom relief. 1, 2

Core Treatment Framework

The management of asthma follows a severity-based stepwise approach with four essential components 1:

• Environmental trigger identification and control to minimize exposure to allergens and irritants 1
• Patient education requiring active self-management responsibility similar to diabetes care 1
• Objective monitoring using peak expiratory flow measurements to track airway obstruction 1
• Pharmacological therapy adjusted according to disease severity and response 1

Stepwise Pharmacological Management

Mild Intermittent Asthma

• Use short-acting beta-agonists (SABA) as needed only - no daily controller medication required 1, 2
• Salbutamol 5 mg or terbutaline 10 mg via nebulizer, or 2 puffs from metered-dose inhaler 10-20 times for acute symptoms 1
• If SABA needed more than 2 days per week or 2 nights per month, escalate to persistent asthma treatment 1

Mild Persistent Asthma

• Start low-dose inhaled corticosteroids as first-line controller therapy - fluticasone propionate 100-250 mcg/day or equivalent 1, 3
• This dose achieves 80-90% of maximum therapeutic benefit 4
• Continue SABA as needed for symptom relief 1
• Alternative second-line options include leukotriene receptor antagonists, though less effective than ICS 1

Moderate Persistent Asthma

• Combine low-dose ICS with long-acting beta-agonist (LABA) - fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily 1, 3
• This combination is superior to doubling the ICS dose for symptom control and lung function 1, 5
• Adding LABA to low-dose ICS provides greater improvement (47 L/min increase in peak flow) compared to doubling ICS dose (24 L/min increase) 5
• The combination does not mask or worsen underlying airway inflammation 6

Severe Persistent Asthma

• Use high-dose ICS plus LABA - fluticasone/salmeterol 500/50 mcg twice daily 1, 3
• Add oral corticosteroids if needed for control 1
• Consider additional controllers such as leukotriene antagonists or sustained-release theophylline 1

Acute Exacerbation Management

Mild to Moderate Exacerbations

• Administer high-dose inhaled beta-agonists immediately - salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen, or 4-12 puffs via MDI with spacer 1, 7
• Give systemic corticosteroids early - prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• Reassess at 15-30 minutes to determine response 1, 7

Severe or Life-Threatening Exacerbations

• Add ipratropium bromide 0.5 mg nebulized to each beta-agonist treatment 1, 7
• Provide high-flow oxygen 40-60% immediately 1, 3
• Consider IV aminophylline 250 mg over 20 minutes or IV salbutamol/terbutaline 250 mcg over 10 minutes 1
• Do not give bolus aminophylline to patients already taking oral theophyllines 1

Hospital Admission Criteria

Immediate referral required for 1, 7:

• Peak expiratory flow <50% predicted after initial treatment 1
• Inability to complete sentences in one breath 7
• Oxygen saturation <92% on room air 7
• Respiratory rate >25 breaths/min or heart rate >110 bpm 7
• Features of life-threatening asthma (hypoxia, hypercapnia, exhaustion, confusion) 1

Self-Management Education

Every patient must receive a written asthma action plan that includes 2, 3:

• Clear distinction between "reliever" medications (SABA) and "preventer" medications (ICS) 2
• Peak flow meter instruction with personal best values and action thresholds 1, 2
• Recognition of worsening symptoms requiring urgent medical attention 2
• Prearranged escalation steps for medication adjustment 3

Monitoring and Follow-Up

Routine Monitoring

• Assess control every 2-6 weeks initially, then every 1-6 months once stable 3
• Verify proper inhaler technique at every visit 2
• Monitor for adverse effects including oral candidiasis, bone mineral density changes, and growth velocity in children 2, 3

Post-Exacerbation Follow-Up

• Primary care visit within 24-48 hours after severe exacerbation 7, 3
• Respiratory specialist appointment within 4 weeks 7
• Continue prednisolone 30-60 mg daily for 1-3 weeks total (not just 5-6 days) 1, 7
• Do not discharge until peak flow >75% predicted or personal best with diurnal variability <25% and no nocturnal symptoms 1, 3

Critical Pitfalls to Avoid

• Never underuse corticosteroids - they are the only therapy that suppresses airway inflammation 8
• Never rely on bronchodilators alone without anti-inflammatory treatment in persistent asthma 2
• Never use sedatives during acute exacerbations - they are absolutely contraindicated 1, 7
• Never prescribe antibiotics unless bacterial infection is clearly documented 1, 7
• Never use percussive physiotherapy during acute exacerbations - it is unnecessary 1
• Never discharge on inadequate steroid duration - the 5-6 day Medrol dose pack is often insufficient 7
• Never combine LABA with another LABA-containing medication due to overdose risk 9

Treatment Adjustments

Step-Down Therapy

• Consider reducing treatment when well-controlled for ≥3 months 3
• When stepping down from fluticasone/salmeterol 250/50 mcg twice daily, reduce to 100/50 mcg twice daily rather than switching to ICS alone 10
• This maintains better asthma control than switching to higher-dose ICS monotherapy 10

Step-Up Therapy

• Before escalating treatment, verify inhaler technique, medication adherence, environmental trigger control, and comorbid conditions 3
• Increasing SABA use (>2 days/week or >2 nights/month) indicates inadequate control requiring intensification of anti-inflammatory therapy 1