What is the order of asthma inhalers for treatment?

Stepwise Order of Asthma Inhalers for Treatment

For chronic asthma management, start with short-acting beta-agonists (SABA) as needed, then add low-dose inhaled corticosteroids (ICS), followed by long-acting beta-agonists (LABA) combined with ICS, and escalate to higher ICS doses with additional controllers as needed. 1

Chronic Asthma Management: Stepwise Approach

Step 1: Intermittent Asthma

• Preferred: Short-acting inhaled beta-agonist (albuterol/salbutamol) as needed for symptom relief 1
• Use metered-dose inhaler (MDI) as initial delivery device 1
• If unable to use MDI properly, add large volume spacer device 1

Step 2: Mild Persistent Asthma

Two evidence-based options exist:

• Option A (Traditional): Low-dose inhaled corticosteroid (ICS) daily PLUS as-needed SABA 1
• Option B (Newer approach): As-needed combination of ICS (beclomethasone 80-250 μg equivalent) and SABA (albuterol) used concomitantly for ages ≥12 years 1, 2

Alternative therapies (if ICS not tolerated): Cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline 1

The as-needed ICS-SABA combination shows equivalent efficacy to daily ICS for asthma control and quality of life, with lower cumulative steroid exposure 1, 2. However, this approach requires patients with normal symptom perception and ability to recognize worsening asthma 1.

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS PLUS long-acting inhaled beta-agonist (LABA) 1
• Alternative preferred: Medium-dose ICS alone 1
• Other alternatives: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 4: Moderate-Severe Persistent Asthma

• Preferred: Medium-dose ICS PLUS LABA 1
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• Preferred: High-dose ICS PLUS LABA 1
• Consider adding: Omalizumab for patients with documented allergies 1

Step 6: Most Severe Persistent Asthma

• Preferred: High-dose ICS PLUS LABA PLUS oral corticosteroid 1
• Consider adding: Omalizumab for allergic patients 1
• Before adding oral steroids, trial of high-dose ICS plus LABA plus leukotriene receptor antagonist may be considered 1

Acute Severe Asthma: Immediate Treatment Order

First-Line Immediate Treatment

1. High-dose inhaled beta-agonist: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen, OR 2 puffs via spacer repeated 10-20 times 1
2. High-dose systemic steroids: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV (oral route equally effective) 1

If Life-Threatening Features Present (PEF <33%, silent chest, cyanosis, confusion)

1. Add ipratropium: 0.5 mg nebulized to the beta-agonist 1
2. Add IV bronchodilator: Aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 μg over 10 minutes 1
   • Critical caveat: Do NOT give bolus aminophylline to patients already taking oral theophyllines 1

Monitoring and Escalation

• Reassess peak expiratory flow 15-30 minutes after initial treatment 1
• Continue nebulized beta-agonist every 4 hours if improving, or every 15 minutes if not improving 1
• Continue high-dose steroids: prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours 1

Key Clinical Decision Points

Trigger to step up treatment: SABA use more than 2-3 times daily or inadequate symptom control 1

When to step down: After 1-3 months of stability and good control 1

Good control defined as: Minimal symptoms, minimal exacerbations, minimal need for rescue bronchodilators, no activity limitations 1

Important Caveats

• Always check compliance and inhaler technique before escalating therapy 1
• Oral steroids for exacerbations do not require tapering when used for ≤2 weeks; can stop from full dose 1
• The as-needed ICS-SABA approach is NOT recommended for ages 0-11 years due to insufficient evidence 1
• Patients with low or high symptom perception may not be suitable for as-needed ICS therapy and should receive regular daily ICS instead 1
• Recent evidence supports anti-inflammatory reliever therapy (combining ICS with SABA) to reduce exacerbations and oral steroid burden 3, 4