What is the recommended treatment approach for asthma?

Asthma Treatment: A Stepwise Approach

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma, with treatment intensity determined by disease severity and stepped up or down based on control. 1

Initial Assessment and Classification

Before initiating treatment, classify asthma severity based on:

• Symptom frequency: Intermittent (<2 days/week), mild persistent (>2 days/week but not daily), moderate persistent (daily), or severe persistent (throughout the day) 2
• Nighttime awakenings: <2x/month (intermittent), 3-4x/month (mild), >1x/week (moderate), or often 7x/week (severe) 3
• SABA use: ≤2 days/week indicates intermittent asthma; >2 days/week signals need for controller therapy 3
• Lung function: Measure FEV1 and FEV1/FVC ratio in patients ≥5 years old 2

Critical caveat: Patients with ≥2 exacerbations requiring oral corticosteroids in the past year should be treated as having persistent asthma regardless of symptom frequency. 3

Stepwise Pharmacological Management

Step 1: Intermittent Asthma

• SABA as needed for symptom relief (albuterol/salbutamol 2 puffs every 4-6 hours as needed) 1
• No daily controller medication required 1

Step 2: Mild Persistent Asthma

• Low-dose ICS daily is the preferred treatment 1
• Specific dosing: Fluticasone propionate 100-250 mcg/day (or equivalent budesonide 200-400 mcg/day) 2, 4
• Important evidence: Low-dose ICS reduces severe exacerbations by 46-52% even in patients with symptoms ≤2 days/week, challenging the traditional symptom-based threshold for starting ICS 5
• Once-daily dosing is as effective as twice-daily for the same total dose and may improve adherence 6

Step 3: Moderate Persistent Asthma

• Low-to-medium dose ICS plus LABA is the preferred option 1, 2
• Specific combination: Fluticasone/salmeterol 100-250/50 mcg twice daily 2, 4
• Alternative: Budesonide/formoterol 160/4.5 mcg twice daily 7

Step 4: Severe Persistent Asthma

• High-dose ICS plus LABA 1
• Fluticasone/salmeterol 500/50 mcg twice daily 4
• Critical warning: High-dose ICS provides minimal additional benefit over moderate doses for most efficacy parameters but increases risk of systemic adverse effects including adrenal suppression, bone density loss, and cataracts 8, 9

Monitoring and Adjusting Treatment

Assessing Control (Every 2-6 Weeks Initially)

• Well-controlled: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, no interference with activities, SABA use ≤2 days/week, FEV1 >80% predicted 3
• Not well-controlled: Symptoms >2 days/week, nighttime awakenings 1-3x/week, some activity limitation, SABA use >2 days/week, FEV1 60-80% predicted 3
• Very poorly controlled: Daily symptoms, nighttime awakenings ≥4x/week, extreme limitation, several-times-daily SABA use, FEV1 <60% predicted 3

Treatment Adjustments

• Step down: Consider after ≥3 months of well-controlled asthma 3, 2
• Step up: If not well-controlled, but first verify inhaler technique, medication adherence, environmental trigger exposure, and comorbid conditions before increasing dose 2
• Key indicator: SABA use >2 days/week or >2 nights/month indicates inadequate control requiring intensification 1

Acute Exacerbation Management

Severity Assessment

Moderate exacerbation (treat at home if response adequate): 3

• Can complete sentences
• Pulse <110 bpm, respirations <25/min
• PEF >50% predicted/personal best

Severe exacerbation (consider hospital admission): 3, 2

• Cannot complete sentences in one breath
• Pulse >110 bpm, respirations >25/min
• PEF <50% predicted/personal best

Life-threatening features (immediate hospital admission): 3

• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia, hypotension, confusion, exhaustion, or coma

Treatment Protocol

For moderate exacerbations: 3

• Nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer
• Oral prednisolone 30-60 mg 3, 1
• Reassess after 15-30 minutes
• If PEF improves to >75% predicted: step up usual treatment and arrange follow-up <48 hours 3

For severe/life-threatening exacerbations: 3, 2

• High-flow oxygen 40-60% 3
• Nebulized albuterol 5 mg every 20-30 minutes for three doses 2
• Add ipratropium bromide 0.5 mg to each nebulization 3, 2
• Oral prednisolone 30-60 mg or IV hydrocortisone 200 mg 3
• Consider IV aminophylline 250 mg over 20 minutes if life-threatening features present 3
• Arrange immediate hospital admission 3

Post-exacerbation follow-up: Primary care within 24-48 hours, do not discharge until PEF >75% predicted/personal best 2

Critical Safety Warnings

• LABA monotherapy increases risk of asthma-related death—never use LABA without ICS 4
• Do not combine with additional LABA-containing medications due to overdose risk 4
• Paradoxical bronchospasm: If occurs, discontinue immediately and use alternative therapy 4
• Oral candidiasis: Rinse mouth with water after each ICS use without swallowing 4
• Pneumonia risk: Increased in COPD patients on ICS; monitor for signs/symptoms 4
• Adrenal suppression: Taper slowly when transferring from systemic corticosteroids; very high ICS doses can cause hypercorticism 4
• Bone density: Assess initially and periodically, especially with prolonged high-dose ICS 2, 4
• Pediatric growth: Monitor growth velocity in children on ICS 2, 4
• Ocular effects: Long-term ICS use increases glaucoma and cataract risk; refer to ophthalmologist if symptoms develop 4

Special Populations and Comorbidities

• Allergic rhinitis, sinusitis, GERD: Evaluate and treat as these worsen asthma control 1
• Annual influenza vaccination recommended for all patients with persistent asthma 1
• Exercise-induced bronchoconstriction: Optimize long-term asthma control first; if symptoms persist, use SABA 15 minutes before exercise 1
• Patients unable to use ICS (e.g., increased intraocular pressure): Leukotriene receptor antagonists are viable non-steroid alternatives 1

Patient Education Essentials

Educate all patients on: 2

• "Relievers" vs. "Preventers": SABA for quick relief, ICS for daily prevention
• Proper inhaler technique: Verify at every visit
• Written asthma action plan: Include symptom/PEF monitoring, prearranged escalation steps, when to seek emergency care
• Trigger avoidance: Identify and minimize exposure to personal triggers