What are the different types of asthma and their corresponding treatment options?

Asthma Classification and Treatment

Primary Classification Systems

Asthma is classified by either severity (for initiating treatment) or control (for ongoing management), with severity-based classification dividing asthma into four categories: intermittent, mild persistent, moderate persistent, and severe persistent. 1

Classification by Severity (For Treatment Initiation)

Severity is determined by assessing both impairment (symptoms, nighttime awakenings, rescue inhaler use, lung function) and risk (exacerbation frequency) before treatment begins 1:

Intermittent Asthma:

• Symptoms ≤2 days/week 1
• Nighttime awakenings ≤2 times/month 1
• Short-acting beta-agonist use ≤2 days/week 1
• FEV1 >80% predicted with normal FEV1/FVC ratio 1
• 0-1 exacerbations requiring oral corticosteroids per year 1

Mild Persistent Asthma:

• Symptoms >2 days/week but not daily 1
• Nighttime awakenings 3-4 times/month 1
• Short-acting beta-agonist use >2 days/week but not daily 1
• FEV1 >80% predicted with normal FEV1/FVC ratio 1
• ≥2 exacerbations requiring oral corticosteroids per year 1

Moderate Persistent Asthma:

• Daily symptoms 1
• Nighttime awakenings >1 time/week but not nightly 1
• Daily short-acting beta-agonist use 1
• FEV1 60-80% predicted with reduced FEV1/FVC ratio 1

Severe Persistent Asthma:

• Symptoms throughout the day 1
• Nighttime awakenings often 7 times/week 1
• Short-acting beta-agonist use several times per day 1
• FEV1 <60% predicted with reduced FEV1/FVC ratio (>5% below normal) 1

Classification by Control (For Ongoing Management)

Once treatment is initiated, asthma should be reclassified by control status rather than severity, as control better predicts treatment response and guides therapeutic adjustments. 1, 2

Well-Controlled Asthma:

• Symptoms ≤2 days/week 1
• Nighttime awakenings ≤2 times/month 1
• No interference with normal activity 1
• Short-acting beta-agonist use ≤2 days/week 1
• FEV1 or peak flow >80% predicted/personal best 1
• 0-1 exacerbations requiring oral corticosteroids per year 1

Not Well-Controlled Asthma:

• Symptoms >2 days/week 1
• Nighttime awakenings 1-3 times/week 1
• Some limitation of normal activity 1
• Short-acting beta-agonist use >2 days/week 1
• FEV1 or peak flow 60-80% predicted/personal best 1

Very Poorly Controlled Asthma:

• Symptoms throughout the day 1
• Nighttime awakenings ≥4 times/week 1
• Extremely limited normal activity 1
• Short-acting beta-agonist use several times per day 1
• FEV1 or peak flow <60% predicted/personal best 1
• ≥2 exacerbations requiring oral corticosteroids per year 1

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• Short-acting beta-agonist as needed only 1, 3
• No daily controller medication required 1, 3

Step 2: Mild Persistent Asthma

Preferred treatment: Low-dose inhaled corticosteroid 1, 3

Alternative options: 1, 3

• Cromolyn sodium
• Leukotriene receptor antagonist
• Nedocromil
• Theophylline

Step 3: Moderate Persistent Asthma

Preferred treatment: Low-dose inhaled corticosteroid plus long-acting beta-agonist 1, 3

Alternative treatment: Medium-dose inhaled corticosteroid alone 1, 3

Other alternatives: 1

• Low-dose/medium-dose inhaled corticosteroid plus leukotriene modifier
• Low-dose/medium-dose inhaled corticosteroid plus theophylline

Step 4: Severe Persistent Asthma

Preferred treatment: High-dose inhaled corticosteroid plus long-acting beta-agonist 1, 3

Additional considerations: 1, 3, 4

• Consider omalizumab (anti-IgE) for patients with allergic asthma
• Oral corticosteroids may be needed
• Consider consultation with asthma specialist 1

Critical Management Principles

Before stepping up treatment, verify: 1, 3

• Medication adherence
• Proper inhaler technique
• Environmental trigger control
• Presence of comorbid conditions (rhinitis, GERD, obesity)

Step down treatment when: 1, 3

• Asthma is well-controlled for at least 3 months
• Reduce dose or frequency of medications gradually
• Continue monitoring closely after step-down

Universal elements at all steps: 1, 3

• Patient education and self-management plan
• Environmental control measures
• Short-acting beta-agonist as needed for all patients
• Annual influenza vaccination for persistent asthma 3

Important Safety Considerations

Long-acting beta-agonists must never be used as monotherapy because this increases the risk of serious asthma-related events including death 1, 5

Inhaled corticosteroids are the most effective single long-term controller medication for improving asthma control across all severity levels 1, 3

Monitor for: 1

• Oral candidiasis (rinse mouth after inhaled corticosteroid use)
• Growth suppression in children
• Bone mineral density loss with long-term use
• Glaucoma and cataracts with prolonged inhaled corticosteroid use

Frequent short-acting beta-agonist use (>2 days/week) indicates poor control and necessitates initiation or escalation of controller therapy 1, 3

Phenotypic Considerations

Different asthma phenotypes exist with varying patterns of inflammation and therapeutic responses, though specific phenotype-directed treatment approaches remain under investigation 1

Common phenotypes include: 6

• Allergic (IgE-mediated) asthma
• Non-allergic asthma (often viral-triggered)
• Occupational asthma
• Aspirin-exacerbated respiratory disease
• Exercise-induced asthma
• Cough-variant asthma