Maintenance Medication for Asthma Home Management
Inhaled corticosteroids (ICS) are the preferred first-line maintenance medication for all patients with persistent asthma, as they are the most effective single long-term controller medication for improving asthma control and reducing exacerbations. 1, 2, 3
First-Line Controller Therapy
Low-dose ICS daily is the recommended starting point for mild persistent asthma (symptoms >2 days/week or nighttime awakenings >2 nights/month). 2, 3 This represents approximately 100-250 μg of fluticasone propionate or equivalent, which achieves 80-90% of maximum therapeutic benefit. 4
- ICS improve asthma control more effectively than leukotriene receptor antagonists (LTRAs), cromolyn, nedocromil, or theophylline in both children and adults. 1
- The dose-response curve for ICS is relatively flat—high doses provide minimal additional benefit over moderate doses but significantly increase systemic side effects. 2, 4
- Starting with 200-250 μg fluticasone propionate equivalent (the "standard daily dose") captures most of the therapeutic benefit while minimizing adverse effects. 4
Alternative First-Line Options (Not Preferred)
If ICS cannot be used due to patient-specific circumstances (e.g., concerns about administration, adherence issues with inhalers):
- LTRAs (montelukast, zafirlukast) are alternative but not preferred options for mild persistent asthma. 1, 3
- Cromolyn and nedocromil are also alternatives but inferior to ICS in effectiveness. 1
- These alternatives should only be considered when ICS administration is genuinely problematic, as ICS demonstrate superior efficacy in lung function, symptom control, and exacerbation reduction. 5
Stepping Up Therapy for Inadequate Control
If symptoms remain uncontrolled on low-dose ICS (SABA use >2×/week or nighttime awakenings >2×/month):
Step 2: Add a long-acting beta-agonist (LABA) to low-dose ICS OR increase to medium-dose ICS alone. 2, 3
- For patients ≥12 years, adding LABA to low-dose ICS is preferred over increasing ICS dose alone. 3
- Critical safety warning: LABA must NEVER be used as monotherapy—this significantly increases risk of exacerbations and death. 2, 3
- Combination ICS-LABA inhalers (e.g., fluticasone-salmeterol) improve adherence and ensure LABA is never taken without ICS. 6
Step 3: Medium-dose ICS-LABA combination. 3
Step 4: Consider adding long-acting muscarinic antagonist (LAMA) to medium-dose ICS-LABA. 3
Step 5-6: High-dose ICS-LABA with consideration of biologics (e.g., omalizumab for allergic asthma) or oral corticosteroids for severe persistent asthma. 1, 3
Monitoring for Treatment Adjustment
Indicators that current therapy is inadequate and requires intensification:
- SABA use more than twice weekly (excluding exercise prophylaxis). 2, 3
- Nighttime awakenings more than twice monthly. 2, 3
- Declining peak expiratory flow or FEV1. 1
Acute Exacerbation Management at Home
For moderate to severe exacerbations:
- Oral systemic corticosteroids (e.g., prednisone) should be initiated promptly. 1, 2, 3
- High-dose nebulized or inhaled SABA for acute symptom relief. 2
- The 2007 guidelines no longer recommend doubling ICS dose for acute exacerbations—this strategy is ineffective. 1
Essential Components of Home Management
Every patient with persistent asthma requires a written asthma action plan detailing:
- How to recognize early warning signs (symptoms, peak flow measurements). 1
- When and how to adjust medications (increase SABA, add oral corticosteroids). 1
- When to seek emergency medical care. 1
Common Pitfalls to Avoid
- Do not delay ICS initiation in persistent asthma—early intervention improves long-term outcomes. 3
- Do not confuse intermittent with persistent asthma—patients using SABA >2×/week need controller therapy, not just rescue inhalers. 3
- Do not prescribe LABA without concurrent ICS—this is associated with increased mortality. 2, 3
- Do not escalate to high-dose ICS monotherapy—adding a second controller (LABA, LTRA, or LAMA) is more effective and safer than high-dose ICS alone. 2, 4