What is the typical daily treatment for a patient with asthma?

Daily Treatment for Asthma

Inhaled corticosteroids (ICS) are the preferred first-line daily controller medication for all patients with persistent asthma, as they are the most effective single agent for improving asthma control and reducing inflammation. 1

Treatment Based on Asthma Severity

Intermittent Asthma

• No daily controller medication is needed 1
• Use short-acting beta2-agonists (SABA) as needed for symptom relief only 2, 1
• SABA should not be used more than twice weekly for symptom control; exceeding this indicates need for daily controller therapy 1

Mild Persistent Asthma

• Low-dose inhaled corticosteroids daily are the preferred treatment 1
• Examples include fluticasone propionate ≥88 mcg/day, budesonide ≥200 mcg/day, or beclomethasone ≥252 mcg/day 2
• SABA as needed for acute symptoms 2

Moderate Persistent Asthma

• Low to medium-dose ICS plus long-acting beta2-agonist (LABA) combination is the preferred option 1
• This combination (ICS-LABA) in a single inhaler improves adherence and provides superior control compared to ICS alone 3, 4
• Never use LABA without ICS, as LABA monotherapy increases risk of serious asthma-related events and mortality 3

Severe Persistent Asthma

• High-dose ICS plus LABA are required 1
• High-dose ICS examples: beclomethasone ≥1,260 mg/day, budesonide ≥1,200 mg/day, fluticasone ≥880 mcg/day 2
• Additional controller medications may be needed, such as leukotriene receptor antagonists (montelukast) 1, 5
• Some patients require frequent oral corticosteroid bursts or chronic daily oral steroids 2, 4

Additional Controller Options

Leukotriene Receptor Antagonists

• Add montelukast 10 mg once daily for patients requiring additional control beyond ICS-LABA, particularly those with allergic asthma 1, 5
• Montelukast is especially effective during allergy season and can attenuate allergen-induced bronchoconstriction 6, 5
• This is a viable non-steroid alternative for patients who cannot use ICS due to side effects like increased intraocular pressure 1

Long-Acting Muscarinic Antagonists

• Tiotropium can be added for patients with inadequate control on ICS-LABA 7

Biologic Agents

• Reserved for severe uncontrolled asthma despite maximal inhaled therapy 8, 7
• Options include omalizumab (anti-IgE), mepolizumab, and reslizumab (anti-IL-5) for specific phenotypes 7

Critical Administration Details

Proper Inhaler Technique

• Rinse mouth with water after each ICS use to reduce risk of oral candidiasis 3
• Use large-volume spacers with metered-dose inhalers to reduce systemic absorption and oropharyngeal side effects 9
• Verify proper technique at every visit, as poor technique is a common cause of apparent treatment failure 6

Dosing Schedule

• ICS-LABA combinations are taken twice daily (morning and evening) 3
• Montelukast is taken once daily in the evening 5
• SABA is used only as needed for acute symptoms, not on a scheduled basis 2

Monitoring Treatment Response

Signs of Inadequate Control

• SABA use more than twice weekly or more than two nights monthly indicates need to intensify anti-inflammatory therapy 1
• Asthma Control Test score <20 indicates poorly controlled asthma requiring treatment escalation 6
• Peak expiratory flow <80% of predicted or diurnal variability >20% suggests inadequate control 2

Follow-Up Schedule

• Reassess patients 2-4 weeks after initiating or changing therapy 6
• Evaluate symptom control, medication adherence, inhaler technique, and environmental triggers at each visit 1
• Once stable, follow-up every 3-6 months 8

Common Pitfalls to Avoid

• Never discontinue ICS when adding LABA or other controllers, as this significantly increases mortality risk 6, 3
• Do not use LABA as monotherapy without concurrent ICS 3
• Avoid high-dose ICS as first step-up, since the dose-response curve is relatively flat beyond moderate doses, with minimal additional benefit but substantially increased systemic side effects 6
• Do not rely solely on patient-reported symptoms for monitoring; objective measures like peak flow and spirometry are essential 2

Adjunctive Measures

• Annual influenza vaccination is recommended for all patients with persistent asthma 1
• Evaluate and treat comorbidities including allergic rhinitis, sinusitis, and gastroesophageal reflux, which worsen asthma control 1
• Implement allergen avoidance strategies for patients with documented sensitization and exposure 2
• Consider subcutaneous immunotherapy as adjunctive treatment for patients with allergic asthma and controlled symptoms 1