What is the recommended management approach for asthma?

Asthma Management

Stepwise Pharmacological Approach

Asthma management requires a stepwise, control-based approach using inhaled corticosteroids (ICS) as the foundation of therapy, with treatment intensity adjusted based on symptom frequency, severity, and response to therapy. 1, 2

Initial Assessment and Classification

• Classify asthma severity at diagnosis based on symptom frequency: intermittent (<2 days/week), mild persistent (>2 days/week but not daily), moderate persistent (daily symptoms), or severe persistent (symptoms throughout the day) 1
• Assess nighttime awakenings, short-acting beta-agonist (SABA) use frequency, and peak expiratory flow (PEF) measurements to guide initial treatment step 1
• Use validated tools such as the Asthma Control Test or asthma APGAR (activities, persistent, triggers, asthma medications, response to therapy) at each visit 2

Step 1: Intermittent Asthma

• Prescribe as-needed short-acting beta-agonists (albuterol/salbutamol) for rescue therapy without daily controller medication 1, 3
• Symptoms occur <2 days/week with <2 nighttime awakenings per month 1

Step 2: Mild Persistent Asthma

• Initiate daily low-dose ICS plus as-needed SABA, or alternatively use as-needed concomitant ICS and SABA therapy 3
• For children aged 4-11 years, use one inhalation of fluticasone/salmeterol 100/50 twice daily 4
• For patients aged 12 years and older, start with fluticasone/salmeterol 100/50 twice daily 4

Step 3: Moderate Persistent Asthma

• Use ICS-formoterol combination as single maintenance and reliever therapy (SMART), which is the preferred approach for adults and adolescents because it reduces severe exacerbations 2, 3
• Prescribe low-dose ICS-formoterol for both daily maintenance and as-needed rescue therapy 3
• For patients aged 12 years and older, consider fluticasone/salmeterol 250/50 one inhalation twice daily 4

Step 4: Moderate-Severe Persistent Asthma

• Increase to medium-dose ICS-formoterol therapy using the SMART approach 3
• Consider fluticasone/salmeterol 500/50 one inhalation twice daily for patients aged 12 years and older 4
• Daily LABA use should not exceed 100 mcg salmeterol or 24 mcg formoterol 1

Step 5: Severe Persistent Asthma

• Add long-acting muscarinic antagonists (LAMA) to ICS-formoterol therapy when asthma remains uncontrolled 3
• Consider specialty referral for evaluation of biologic agents in patients with severe allergic or eosinophilic asthma 2

Critical Treatment Principles

Long-Acting Beta-Agonist Safety

• Never use LABA as monotherapy—LABAs must always be combined with ICS due to increased risk of severe asthma-related events and death 1, 4
• Patients must be instructed not to stop ICS therapy while taking LABA, even if symptoms significantly improve 1
• Do not combine with additional LABA-containing medications due to overdose risk 4

Acute Exacerbation Management

• Administer high-dose nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg) with oxygen immediately 1, 5
• Give systemic corticosteroids early: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1, 5, 6
• Measure PEF 15-30 minutes after initial treatment to assess response 1, 5
• Add ipratropium 0.5 mg nebulized if response is inadequate after initial bronchodilator therapy 1, 5

Hospitalization Criteria

• Admit patients with PEF <50% predicted after initial treatment, inability to complete sentences in one breath, oxygen saturation <92% on room air, or any life-threatening features 1, 5, 7
• Life-threatening features include PEF <33% predicted, silent chest, cyanosis, weak respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1, 7
• Lower the threshold for admission if the attack occurs in afternoon/evening, recent nocturnal symptoms, previous severe attacks, or recent hospital admission 1, 5

Adjunctive Therapies

Allergen Immunotherapy

• Consider subcutaneous allergen immunotherapy for patients aged 5 years and older with mild to moderate persistent allergic asthma as adjunct to standard pharmacotherapy 1, 3
• Sublingual immunotherapy is not recommended specifically for asthma 3
• Clinicians administering immunotherapy must be prepared to identify and treat anaphylaxis 1

Fractional Exhaled Nitric Oxide (FeNO)

• Use FeNO testing to assist in diagnosis and monitoring of symptoms, but not alone to diagnose or monitor asthma 3

Indoor Allergen Mitigation

• Recommend allergen mitigation only in patients with documented exposure and relevant sensitivity or symptoms 3
• When used, allergen mitigation should be allergen-specific and include multiple strategies 3

Monitoring and Follow-Up

• Assess control at every visit and step up therapy if asthma is not well controlled (check inhaler technique, adherence, environmental triggers, and comorbid conditions first) 1
• Step down therapy if asthma is well controlled for at least 3 months 1
• Provide all patients with a peak flow meter and written asthma action plan 6
• Schedule follow-up within 48 hours after acute exacerbation managed at home, or within 24 hours after emergency department visit 1
• Arrange specialist respiratory review within 1 month for patients with severe exacerbations 5

Common Pitfalls to Avoid

• Never prescribe sedatives to asthmatic patients—they are absolutely contraindicated and can cause fatal respiratory depression 6, 7
• Do not prescribe antibiotics unless bacterial infection is clearly documented 6, 7
• Do not recommend short-term increases in ICS dose alone for worsening symptoms 3
• Avoid bronchial thermoplasty as part of standard care; if used, it should only be within research protocols 3

Systemic Corticosteroid Tapering

• When transferring patients from systemic corticosteroids to ICS therapy, taper prednisone slowly by reducing the daily dose by 2.5 mg weekly 4
• Monitor lung function (FEV1 or morning PEF), beta-agonist use, and asthma symptoms carefully during withdrawal 4
• Observe for signs of adrenal insufficiency including fatigue, weakness, nausea, vomiting, and hypotension 4

Special Populations

• Monitor growth in pediatric patients on ICS therapy 1, 4
• Assess bone mineral density initially and periodically in patients on long-term ICS 1, 4
• Consider ophthalmology referral for patients on long-term ICS who develop ocular symptoms, as glaucoma and cataracts may occur 1, 4
• Use caution in patients with cardiovascular disorders, convulsive disorders, thyrotoxicosis, or diabetes mellitus due to beta-adrenergic effects 4