What is the recommended treatment approach for managing asthma?

Asthma Management: A Stepwise Treatment Approach

For newly diagnosed asthma in adults, initiate low-dose inhaled corticosteroid (ICS) as first-line controller therapy with as-needed short-acting beta-agonist (SABA) for symptom relief, and escalate treatment in a stepwise fashion based on severity and control. 1, 2

Initial Assessment and Classification

Before initiating treatment, determine asthma severity by evaluating:

• Daytime symptoms frequency (≤2 days/week suggests intermittent asthma) 2
• Nighttime awakenings (≤2 times/month indicates intermittent disease) 2
• SABA use for symptom relief (>2 days/week signals need for controller therapy) 2
• Interference with normal activities 2
• Objective lung function using FEV1 or peak expiratory flow (PEF), with values ≥80% predicted indicating well-controlled asthma 1

Stepwise Treatment Algorithm

Step 1: Intermittent Asthma

• As-needed SABA only (albuterol/salbutamol) for symptoms occurring ≤2 days per week 2, 3
• No daily controller medication required 2

Step 2: Mild Persistent Asthma

• Low-dose ICS (fluticasone 100-250 mcg daily or equivalent) as preferred controller 1, 2
• As-needed SABA for acute symptom relief 2
• Alternative options (less effective): cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline 2

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta-agonist (LABA) as preferred combination 1
• Single maintenance and reliever therapy (SMART) with ICS-formoterol is preferred for adults and adolescents, as it reduces severe exacerbations 4, 3
• Alternative: medium-dose ICS monotherapy 1

Step 4: Moderate-to-Severe Persistent Asthma

• Medium-dose ICS plus LABA (specifically ICS-formoterol for both daily and as-needed use) 1, 3
• Alternative options: medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• Medium-dose ICS-formoterol therapy with addition of long-acting muscarinic antagonist (LAMA) if not controlled 1, 3
• Consider high-dose ICS plus LABA 1
• Consider omalizumab for patients with allergic asthma 1

Step 6: Most Severe Asthma

• High-dose ICS plus LABA plus LAMA 1
• Addition of oral corticosteroids may be necessary 1
• Consider biologic agents for severe allergic and eosinophilic asthma 4

Acute Exacerbation Management

Severity Assessment

Assess using objective measures including 5:

• Ability to speak in complete sentences (inability indicates severe exacerbation) 5
• Respiratory rate (>25 breaths/min indicates severe disease) 5
• Heart rate (>110 beats/min suggests severity) 5
• Peak expiratory flow (<50% predicted indicates severe exacerbation) 5

Mild Exacerbations (PEF >50% predicted)

• Nebulized salbutamol 5 mg or terbutaline 10 mg 5
• Monitor response 15-30 minutes after nebulizer 5
• If PEF 50-75% predicted after bronchodilator: prednisolone 30-60 mg 5
• Follow-up within 48 hours 5

Severe Exacerbations (PEF <50% predicted, inability to complete sentences, pulse >110, respirations >25)

• Oxygen 40-60% if available 5
• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas 5
• Prednisolone 30-60 mg or IV hydrocortisone 200 mg 5
• Add ipratropium 0.5 mg nebulized for additional bronchodilation 5
• Arrange hospital admission if any signs of acute severe asthma persist after initial treatment 5
• Follow-up within 24 hours if managed as outpatient 5

Life-Threatening Features (requiring immediate hospitalization)

• Silent chest, cyanosis, feeble respiratory effort 5
• Bradycardia, confusion, exhaustion, or coma 5
• Oxygen saturation <92% on room air 6
• PEF <33% predicted 5

Essential Management Components

Patient Education

• Provide written asthma action plan with green, yellow, and red zone instructions 2
• Teach proper inhaler technique and verify at each visit 1, 2
• Explain difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1
• Instruct on environmental control measures and trigger avoidance 2

Monitoring and Follow-up

• Schedule visits every 2-6 weeks initially to assess response to therapy 2
• Monitor for SABA overuse (>2 days/week suggests inadequate control and need to step up therapy) 2
• Regular peak flow monitoring using a peak flow meter 1
• Once control achieved, extend intervals to every 1-6 months 2

When to Escalate Therapy

• If symptoms persist despite low-dose ICS after 4-6 weeks, add LABA to low-dose ICS or increase to medium-dose ICS 2
• Consider step-down of therapy only when asthma has been stable for at least 3 months 1

Critical Pitfalls to Avoid

• Never use SABA monotherapy for persistent asthma—this approach is strongly discouraged and increases risk of serious asthma-related events 7, 8
• Do not underestimate severity of exacerbations—delay can be fatal 5
• Avoid underuse of corticosteroids in acute exacerbations 5
• Do not use LABA without ICS—LABA monotherapy increases risk of serious asthma-related events 7
• Do not combine Wixela Inhub (or similar ICS-LABA combinations) with additional LABA-containing medications due to overdose risk 7
• Never use sedation in acute asthma 1
• Do not delay systemic corticosteroids during severe exacerbations 1

Special Considerations

Comorbidities

• Assess for GERD, rhinosinusitis, and obstructive sleep apnea in adult-onset asthma 2
• Consider occupational exposures as potential triggers 2

Adjunctive Therapies

• Subcutaneous allergen immunotherapy may be considered for patients aged 5 years and older with mild to moderate allergic asthma and identified allergic triggers 1, 2, 3
• Sublingual immunotherapy is not recommended specifically for asthma 1, 3
• Fractional exhaled nitric oxide (FeNO) testing can assist in diagnosis and monitoring but should not be used alone 1, 3

Referral Indications

• Refer to pulmonary specialist if severe uncontrolled asthma persists despite appropriate treatment 1, 4
• Consider referral to ophthalmologist for patients on long-term ICS due to risk of glaucoma and cataracts 7