From the Guidelines
For asthma management, I recommend a stepwise approach based on symptom severity, as outlined in the Expert Panel Report 3 (EPR-3) guidelines 1.
Key Components of Asthma Management
- For mild intermittent asthma, prescribe a short-acting beta-agonist (SABA) like albuterol (90 mcg, 2 puffs every 4-6 hours as needed) 1.
- For persistent asthma, start with a low-dose inhaled corticosteroid (ICS) such as fluticasone (100-250 mcg twice daily) or budesonide (180-360 mcg twice daily) 1.
- If symptoms persist, step up to a combination ICS/long-acting beta-agonist (LABA) like fluticasone/salmeterol (Advair 250/50 mcg, 1 puff twice daily) or budesonide/formoterol (Symbicort 160/4.5 mcg, 2 puffs twice daily) 1.
- For severe cases, add a long-acting muscarinic antagonist (LAMA) like tiotropium (Spiriva 2.5 mcg, 2 puffs once daily) 1.
Patient Education and Follow-Up
- All patients should have an asthma action plan and be educated on proper inhaler technique 1.
- Regular follow-up is essential to assess control and adjust therapy as needed, with consideration of stepping down medication for patients with well-controlled asthma to minimize risks of adverse effects 1. This stepwise approach targets the underlying airway inflammation and bronchospasm that characterize asthma, with treatment intensity matching symptom severity to achieve optimal control while minimizing medication side effects.
From the Research
Asthma Treatment Options
The treatment of asthma can be managed through various protocols, including the use of inhaled corticosteroids (ICS) and long-acting beta2-agonists (LABAs).
- The SMART (Single Maintenance and Reliever Therapy) protocol is a recommended approach for managing asthma, which involves the use of a single inhaler containing a combination of ICS and LABA for both maintenance and quick relief therapy 2.
- Studies have shown that combined salmeterol/fluticasone propionate is effective in improving lung function and reducing asthma symptoms in patients with mild to severe asthma 3, 4, 5.
- The use of SMART with budesonide-formoterol has been confirmed to be efficacious and safe, and is recommended for steps 3 and 4 of asthma management 2.
Prescription Recommendations
Based on the available evidence, the following prescription recommendations can be made:
- For patients with mild asthma, once-daily salmeterol/fluticasone propionate combination (SFC) 50 microg/100 microg can be prescribed 5.
- For patients with moderate to severe asthma, low-dose to medium-dose SMART and high-dose ICS/LABA+as-needed short-acting β2-agonist can be effective in reducing the risk of severe asthma exacerbation 6.
- The SMART regimen should be introduced with a careful explanation of its role in self-management, preferably with a customized written asthma action plan 2.
Key Considerations
When prescribing asthma treatment, the following key considerations should be taken into account: