From the Guidelines
The 5 steps of progressive asthma treatment involve a stepwise approach, starting with as-needed short-acting beta-agonists (SABAs) for mild symptoms, and escalating to combination therapies with inhaled corticosteroids (ICS), long-acting beta-agonists (LABAs), and other controllers for more severe symptoms, as outlined in the expert panel report 3 (EPR-3) guidelines 1. The steps are designed to assist clinical decision-making, with the goal of achieving and maintaining asthma control, while minimizing morbidity, mortality, and improving quality of life.
- Step 1 involves as-needed SABAs like albuterol for mild, intermittent symptoms.
- Step 2 adds daily low-dose ICS such as fluticasone or budesonide, or alternatively a leukotriene modifier like montelukast.
- Step 3 escalates to combination therapy with low-dose ICS plus a LABA such as fluticasone/salmeterol or budesonide/formoterol, or medium-dose ICS alone.
- Step 4 increases to medium-dose ICS/LABA combinations, possibly adding a long-acting muscarinic antagonist (LAMA) like tiotropium.
- Step 5, for severe asthma, involves high-dose ICS/LABA combinations plus additional controllers such as tiotropium, biologics (omalizumab, mepolizumab, benralizumab), or oral corticosteroids, as recommended in the EPR-3 guidelines 1. It is essential to regularly reassess asthma control, inhaler technique, adherence, and triggers at each step, and to adjust treatment accordingly, to ensure optimal management of asthma and minimize the risk of exacerbations and morbidity 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Progressive Asthma Treatment Steps
The following are the steps for progressive asthma treatment:
- Step 1: Intermittent Asthma: As-needed short-acting β2-agonists (SABAs) for rescue therapy 2
- Step 2: Mild Persistent Asthma: Either daily low-dose ICS plus as-needed SABA therapy or as-needed concomitant ICS and SABA therapy 2
- Step 3: Moderate Persistent Asthma: Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) with low-dose ICS-formoterol therapy 2
- Step 4: Moderate Persistent Asthma: Formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) with medium-dose ICS-formoterol therapy 2
- Step 5: Moderate-Severe Persistent Asthma: Add-on long-acting muscarinic antagonists for individuals whose asthma is not controlled by ICS-formoterol therapy 2
Key Considerations
Some key considerations for asthma treatment include:
- The use of fluticasone propionate and salmeterol combination product for initial maintenance therapy in patients with persistent asthma 3, 4
- The addition of montelukast or salmeterol to fluticasone for protection against asthma attacks 5
- The comparison of fluticasone/budesonide and formoterol/salmeterol in asthma treatment 6