What are the steps in treating asthma?

Asthma Stepwise Treatment Approach

Asthma treatment follows a 6-step escalation approach, with all patients requiring short-acting beta-agonists for rescue therapy and each step building upon the previous with increasing intensity of anti-inflammatory and bronchodilator medications. 1

Universal Principles Across All Steps

• Patient education, environmental control, and management of comorbidities must be addressed at every treatment step 1
• All patients require quick-relief medication (short-acting beta-agonist as needed) regardless of severity 1
• Consider subcutaneous allergen immunotherapy for patients with allergic asthma in Steps 2-4 1, 2
• Step up treatment if using short-acting beta-agonist more than 2 days per week for symptom relief (excluding exercise-induced bronchospasm prevention), as this indicates inadequate control 1

Step 1: Intermittent Asthma

Preferred treatment: Inhaled short-acting beta-agonist as needed only 1, 2

• No daily controller medication required at this step 2
• This applies to patients with symptoms less than once per week 2

Step 2: Mild Persistent Asthma

Preferred treatment: Low-dose inhaled corticosteroid (ICS) daily 1, 2

Alternative options (if preferred treatment fails or is not tolerated):

• Cromolyn 1
• Leukotriene receptor antagonist 1, 2
• Nedocromil 1
• Theophylline (requires serum concentration monitoring) 1

Important: If alternative treatment produces inadequate response, discontinue it and use the preferred treatment before stepping up 1

Step 3: Moderate Persistent Asthma

Preferred treatment (two equally acceptable options):

• Low-dose ICS plus long-acting beta-agonist (LABA) 1, 2
• OR Medium-dose ICS alone 1, 2

Alternative options:

• Low-dose ICS plus leukotriene receptor antagonist 1, 2
• Low-dose ICS plus theophylline (requires monitoring) 1
• Low-dose ICS plus zileuton (less desirable due to limited studies and need for liver function monitoring) 1

Critical safety note: LABAs should never be used as monotherapy—they must always be combined with ICS 1, 3

Step 4: Moderate-to-Severe Persistent Asthma

Preferred treatment: Medium-dose ICS plus LABA 1, 2

Alternative options:

• Medium-dose ICS plus leukotriene receptor antagonist 1
• Medium-dose ICS plus theophylline (requires monitoring) 1
• Medium-dose ICS plus zileuton (less desirable) 1

Consider consultation with an asthma specialist at this level 2

Step 5: Severe Persistent Asthma

Preferred treatment: High-dose ICS plus LABA 1, 2

Additional consideration: Add omalizumab for patients with documented allergies 1, 2

• Omalizumab reduces need for both oral and inhaled steroids (NNT = 6-12) and reduces exacerbations in approximately 15% of patients (NNT = 6) 1
• Indicated for patients 12 years and older with severe persistent asthma and demonstrated immediate hypersensitivity 1

Step 6: Most Severe Persistent Asthma

Preferred treatment: High-dose ICS plus LABA plus oral corticosteroid 1, 2

Additional consideration: Add omalizumab for patients with allergies 1

Alternative approach before introducing oral corticosteroids: Trial of high-dose ICS plus LABA plus either leukotriene receptor antagonist, theophylline, or zileuton (though this approach lacks clinical trial evidence) 1

Treatment Adjustment Algorithm

When to Step Up Treatment

Before stepping up, always verify: 2

• Inhaler technique is correct 2
• Medication adherence is adequate 2
• Environmental triggers are controlled 2
• Comorbid conditions are managed 2

Step up if: Using rescue inhaler more than 2 days per week for symptoms, experiencing nighttime awakenings, or having activity limitations 1, 2

When to Step Down Treatment

Step down only if asthma is well controlled for at least 3 months 1, 2

• Schedule follow-up every 2-6 weeks when initiating therapy or stepping up 2
• Schedule follow-up every 1-6 months after control is achieved 2
• Schedule follow-up every 3 months if step-down is anticipated 2

Critical Safety Considerations and Common Pitfalls

Monitoring Requirements

• Assess inhaler technique at every visit 2
• Monitor for local effects of ICS: Oral candidiasis (thrush), dysphonia—advise patients to rinse mouth with water without swallowing after each use 1, 2, 3
• Monitor for systemic effects with high-dose ICS: Adrenal suppression, decreased bone mineral density, growth suppression in children, glaucoma, cataracts 2, 3
• Perform spirometry at initial assessment, after treatment stabilization, during worsening symptoms, and at least every 1-2 years 2

Pitfalls to Avoid

• Underestimating severity: Leads to inadequate anti-inflammatory treatment 2
• Overreliance on short-acting beta-agonists: Indicates poor control and need to step up 2
• Failure to step down when appropriate: Exposes patients to unnecessary medication risks 2
• Using LABA without ICS: Increases risk of serious asthma-related events 1, 3
• Not checking adherence before escalating: Many treatment failures are due to poor technique or non-adherence 2

Special Warnings

• Never use asthma controller medications for acute symptom relief—they are not designed for immediate bronchodilation 1, 2
• Increased pneumonia risk in COPD patients on ICS/LABA combinations—monitor for signs and symptoms 3
• Paradoxical bronchospasm can occur—if it does, discontinue immediately and institute alternative therapy 3