What is the recommended step 2 asthma therapy for an older adult with uncontrolled asthma?

Step 2 Asthma Therapy for Older Adults

For older adults with mild persistent asthma requiring Step 2 therapy, initiate low-dose inhaled corticosteroids (ICS) at 200-250 μg/day of beclomethasone equivalent (or 100-250 μg/day fluticasone equivalent) administered twice daily, with as-needed short-acting beta-agonist (SABA) for quick relief. 1, 2

Primary Recommendation: Low-Dose ICS

• Low-dose ICS represents the preferred Step 2 therapy for mild persistent asthma in adults aged 12 years and older, including older adults 1
• Specific low-dose regimens include:
  • Beclomethasone dipropionate 200-500 μg/day 2
  • Budesonide 200-400 μg/day 2
  • Fluticasone propionate 100-250 μg/day 2
• ICS are the most effective single long-term controller medication for persistent asthma, superior to leukotriene modifiers, theophylline, or cromones 2

Alternative Step 2 Option for Select Patients

• For older adults aged 12 years and older who may have adherence concerns with daily therapy, as-needed ICS plus SABA used concomitantly (one after the other) represents an acceptable alternative 1, 2
• This intermittent approach involves 2-4 puffs of albuterol followed by 80-250 μg of beclomethasone equivalent every 4 hours as needed for asthma symptoms 1
• Studies demonstrate no differences in asthma control, quality of life, or exacerbation frequency between daily low-dose ICS and intermittent ICS when used with SABA 1
• This alternative should NOT be used in patients with low or high symptom perception, as they may undertreat or overtreat their asthma 1

Alternative Medications (Less Preferred)

If ICS cannot be used, alternative Step 2 options include:

• Leukotriene receptor antagonists (montelukast or zafirlukast) - easier to use with high compliance rates but less effective than ICS 1, 2
• Cromolyn, nedocromil, or theophylline (with serum concentration monitoring) 1

Critical Monitoring Parameters

• SABA use frequency serves as the primary indicator for treatment adequacy: use more than 2 days per week for symptom relief indicates inadequate control and need to step up to Step 3 therapy 1, 3
• Assess symptom control, medication adherence, and environmental triggers at every visit 1, 3
• Verify proper inhaler technique before considering treatment failure or dose escalation 2

Age-Specific Considerations for Older Adults

• The fundamental approach of low-dose ICS remains appropriate regardless of age 3
• Pay particular attention to comorbidities (COPD overlap, cardiovascular disease, osteoporosis) that may complicate asthma management in older adults 3
• Consider potential drug interactions with medications commonly used in older adults 3
• Assess for cognitive or physical limitations that may affect inhaler technique 2

When to Step Up to Step 3 Therapy

If asthma remains uncontrolled on low-dose ICS alone:

• Add a long-acting beta-agonist (LABA) to low-dose ICS rather than increasing ICS dose - this provides greater improvement in lung function, symptoms, and exacerbation reduction 2, 4
• The combination of ICS/LABA is more effective than doubling or quadrupling the ICS dose 4, 5
• LABAs must NEVER be used as monotherapy due to increased risk of severe exacerbations and deaths 1, 2, 6

Common Pitfalls to Avoid

• Failing to recognize when SABA use exceeds 2 days per week, which indicates progression requiring controller therapy 1, 3
• Starting with high-dose ICS provides no clinically meaningful advantage over low-dose ICS (only 5% improvement in FEV1) but increases side effect risk 2
• Prescribing LABAs without concurrent ICS therapy 1, 2, 6
• Inadequate assessment of inhaler technique before escalating therapy 2
• Not addressing environmental triggers and comorbid conditions before stepping up treatment 1