What is the first line treatment for a patient with asthma?

First-Line Treatment for Asthma

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma, as they improve asthma control more effectively than any other single long-term control medication. 1, 2

Treatment Based on Asthma Severity

Intermittent Asthma

• No daily controller medication is needed 1, 2
• Use short-acting beta-agonists (SABA) as needed for symptom relief only 1, 3
• If SABA is needed more than 2 days per week (excluding exercise-induced symptoms), the patient likely has persistent asthma requiring controller therapy 1, 2

Mild Persistent Asthma

• Start with low-dose inhaled corticosteroids as first-line therapy 1, 2
• Specific low-dose options include: beclomethasone 200-500 mcg/day, budesonide 200-400 mcg/day, or fluticasone 100-250 mcg/day 4
• Alternative second-line option: Leukotriene receptor antagonists (LTRA) for patients who cannot or will not use ICS 1, 2
• LTRAs have high compliance rates and provide good symptom control in many patients, though less effective than ICS 1

Moderate Persistent Asthma

• Preferred treatment: Low-to-medium dose ICS plus long-acting beta-agonist (LABA) combination 1, 2, 4
• Alternative: Increase to medium-dose ICS alone, though combination therapy is superior 1, 4
• For patients ≥12 years, adding LABA to ICS is preferred over simply increasing ICS dose 1, 2

Severe Persistent Asthma

• High-dose ICS plus LABA combination 1, 2, 3
• Consider adding tiotropium (LAMA), or biologics (omalizumab for allergic asthma) 1
• May require oral corticosteroids, though minimize use due to systemic side effects 1

Rescue Medication for All Severity Levels

• SABA as needed for acute symptom relief 1
• SABA use >2 days/week or >2 nights/month indicates inadequate control and need to step up controller therapy 1, 2
• SABA is the most effective therapy for rapid reversal of airflow obstruction 1

Critical Safety Warnings

Never Use LABA as Monotherapy

• LABA used alone (without ICS) increases risk of asthma exacerbations and death 1, 2, 4
• Always combine LABA with ICS in the same inhaler or as separate inhalers 1, 5

When to Step Up Treatment

• Increasing SABA use (>2 days/week for symptom relief) 1, 2
• Nighttime awakenings >2 nights/month 1, 4
• Using more than one SABA canister per month 4
• Any exacerbation requiring oral corticosteroids 1

Management of Acute Exacerbations

• Moderate to severe exacerbations: Oral systemic corticosteroids (prednisolone 30-60 mg daily for 5-10 days) 1, 4, 3
• High-dose nebulized SABA (salbutamol 5 mg or terbutaline 10 mg) repeated every 4-6 hours 1, 3
• Add ipratropium bromide 500 mcg if inadequate response to SABA 1
• Provide supplemental oxygen to maintain saturation 1, 4

Common Pitfalls to Avoid

• Do not delay initiating ICS in persistent asthma – early intervention improves long-term outcomes 2, 4, 3
• Do not confuse intermittent with persistent asthma – patients using SABA >2 days/week need controller therapy 2, 4
• Do not use LABA without concurrent ICS – this significantly increases mortality risk 1, 2, 4
• Do not double ICS dose for home management of acute exacerbations – use oral corticosteroids instead 1
• Rinse mouth after ICS use to reduce risk of oral candidiasis 1, 5

Monitoring Treatment Response

• Schedule follow-up visits every 3-6 months for patients on controller medications 1, 3
• Assess symptom control, SABA use frequency, nighttime awakenings, and peak flow measurements 1
• Consider stepping down therapy after 3 months of well-controlled asthma 1
• Refer to asthma specialist if requiring Step 4 or higher care, or if >2 oral corticosteroid bursts needed per year 1