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

• Use short-acting beta-agonists (SABA) as needed for symptom relief only 1, 2
• No daily controller medication is required 1, 3
• If SABA is needed more than 2 days per week (excluding pre-exercise use), this indicates persistent asthma requiring controller therapy 1

Mild Persistent Asthma

• Start with low-dose inhaled corticosteroids as first-line therapy 1, 2, 3
• Specific low-dose options include: beclomethasone dipropionate 200-500 mcg/day, budesonide 200-400 mcg/day, or fluticasone propionate 100-250 mcg/day 4
• Alternative second-line option: leukotriene receptor antagonists (LTRA) for patients who cannot or will not use ICS 1, 2
• Add SABA as needed for quick symptom relief 2, 4

Moderate Persistent Asthma

• Initiate low-to-medium dose ICS plus long-acting beta-agonist (LABA) combination 1, 2, 3
• This combination is superior to increasing ICS dose alone 4
• Alternative: medium-dose ICS monotherapy if combination therapy is not feasible 1

Severe Persistent Asthma

• Start with high-dose ICS plus LABA 1, 3
• Consider adding long-acting muscarinic antagonist (LAMA) if control remains inadequate 2
• Refer to specialist for consideration of biologics (omalizumab, anti-IL5, anti-IL4R) 1, 2

Critical Safety Warnings

Never use LABA as monotherapy for asthma—this increases risk of exacerbations and death 1, 2, 4

• LABA must always be combined with ICS 2, 4
• Do not use LABA in combination with another LABA-containing medication due to overdose risk 5

Monitoring for Inadequate Control

Signs requiring treatment intensification include: 1, 2, 4

• SABA use more than 2 days per week for symptom relief
• Nighttime awakenings more than 2 nights per month
• Using more than one SABA canister per month
• Any exacerbation requiring oral corticosteroids

Acute Exacerbation Management

For moderate to severe exacerbations: 1, 3

• Administer oral systemic corticosteroids (prednisolone 30-60 mg daily for 5-10 days)
• High-dose nebulized SABA (salbutamol 5 mg or terbutaline 10 mg) repeated every 20 minutes up to 3 times
• Add ipratropium bromide 500 mcg if response is inadequate 1
• Provide supplemental oxygen to maintain saturation >90% 1

Common Pitfalls to Avoid

• Do not delay initiating ICS in persistent asthma—early intervention improves long-term outcomes 2, 4
• Do not confuse intermittent with persistent asthma—patients using SABA more than twice weekly need controller therapy 2
• Do not start with high-dose ICS—low doses are equally effective for most efficacy parameters with fewer safety concerns 6
• Do not use SABA alone for long-term management—this indicates inadequate anti-inflammatory control 1

Additional Considerations

• Advise patients to rinse mouth with water after ICS use to reduce risk of oral candidiasis 5
• ICS are safe in renal failure as they have minimal systemic absorption 4
• For patients with contraindications to ICS (e.g., severe glaucoma), LTRA may be used as alternative controller 3
• All patients should receive written asthma action plans detailing medication adjustments and when to seek emergency care 1