What is the step-wise management of asthma?

From the Guidelines

Stepwise asthma management involves treating patients according to the severity of their condition, with treatment intensity increasing or decreasing based on symptom control, as recommended by the expert panel report 3 (EPR-3) guidelines for the diagnosis and management of asthma-summary report 2007 1.

Key Components of Stepwise Asthma Management

• Assessing and monitoring asthma severity and control
• Classifying asthma severity based on current impairment and future risk
• Adjusting therapy based on asthma control
• Using a stepwise approach to manage asthma, with treatment intensity increasing or decreasing based on symptom control

Stepwise Approach for Managing Asthma

• For mild intermittent asthma, a short-acting beta-agonist (SABA) like albuterol (2 puffs every 4-6 hours as needed) is sufficient
• For mild persistent asthma, add a low-dose inhaled corticosteroid (ICS) such as fluticasone (88-264 mcg daily) or budesonide (180-540 mcg daily)
• For moderate persistent asthma, use a low-dose ICS plus a long-acting beta-agonist (LABA) like fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort), or increase to medium-dose ICS
• For severe persistent asthma, use medium to high-dose ICS plus LABA, and consider adding a long-acting muscarinic antagonist (LAMA) like tiotropium or biological therapies for specific phenotypes, as recommended by the EPR-3 guidelines 2, 3, 4

Regular Assessment and Adjustment of Therapy

• Regular assessment of control using tools like the Asthma Control Test guides step-up or step-down therapy
• Assess control in 2 to 6 weeks (depending on level of initial severity or control) and adjust therapy accordingly
• Consider stepping up therapy if asthma control is not achieved, and stepping down therapy if asthma is well controlled for at least three months, as recommended by the EPR-3 guidelines 1, 4

From the FDA Drug Label

For oral inhalation only. • Treatment of asthma in patients aged 12 years and older: 1 inhalation of Wixela Inhub® 100/50, Wixela Inhub® 250/50, or Wixela Inhub® 500/50 twice daily. Starting dosage is based on asthma severity. • Treatment of asthma in patients aged 4 to 11 years: 1 inhalation of Wixela Inhub® 100/50 twice daily.

The step-wise approach for asthma treatment is not explicitly outlined in the provided drug labels. However, the labels do provide information on the treatment of asthma in patients aged 4 years and older, with specific dosage recommendations based on age and asthma severity.

• Asthma treatment in patients aged 12 years and older: 1 inhalation of Wixela Inhub® 100/50, Wixela Inhub® 250/50, or Wixela Inhub® 500/50 twice daily, with the starting dosage based on asthma severity.
• Asthma treatment in patients aged 4 to 11 years: 1 inhalation of Wixela Inhub® 100/50 twice daily. 5

From the Research

Step-Wise Asthma Management

• Asthma management requires a stepwise approach, escalating and de-escalating treatment based on symptom control 6
• The stepwise approach for asthma treatment involves adjusting treatment based on the level of symptom control, with the goal of achieving and maintaining control while minimizing side effects and costs 7, 6
• The Global Initiative for Asthma (GINA) guidelines recommend that all asthma patients be treated with inhaled corticosteroids taken daily or as needed, and that treatment be adjusted based on symptom control 6

Treatment Steps for Asthma

• Step 1 treatment for asthma: As-needed low-dose ICS-formoterol is recommended for patients with limited to occasional transient daytime symptoms, no nocturnal symptoms, no risk of exacerbations, and FEV1 > 80% predicted 8
• Step 2 treatment for asthma: As-needed low-dose ICS-formoterol is recommended, and significantly reduces moderate-to-severe exacerbations compared with short-acting β2-agonist (SABA) monotherapy 8
• For patients with persistent symptoms or exacerbations despite correct inhalation technique and adherence to Step 4 treatment, referral to asthma specialists or specialized clinics for further evaluation is recommended 8

Adjusting Treatment

• Treatment should be adjusted based on symptom control, with the goal of achieving and maintaining control while minimizing side effects and costs 7, 6
• The treatment approach should be individualized, taking into account the patient's specific needs and circumstances, and should involve a collaborative effort between the patient and healthcare provider 7
• A pragmatic approach that sets therapeutic goals for each individual and associates them with the treatable traits of asthma may be more effective than the traditional stepwise approach 7

Combination Therapy

• Combination treatment with inhaled corticosteroids (ICS) and long-acting beta2-adrenoceptor agonists (LABAs) is effective for patients with moderate to severe asthma 9, 10
• The combination of ICS and LABA provides greater asthma control than increasing the ICS dose alone, while reducing the frequency and severity of exacerbations 10
• The use of a combination inhaler containing both ICS and LABA can improve patient adherence and reduce morbidity 10