What is the recommended treatment plan for a patient with asthma?

Asthma Treatment: Stepwise Pharmacological Approach

For adults and adolescents ≥12 years with asthma, initiate treatment based on severity classification using a stepwise approach, with inhaled corticosteroids (ICS) as the cornerstone of therapy for all persistent asthma, and short-acting beta-agonists (SABA) reserved for symptom relief. 1, 2

Initial Assessment and Severity Classification

Before initiating therapy, classify asthma severity to determine the appropriate starting step 2:

• Intermittent asthma: Symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, SABA use ≤2 days/week
• Mild persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4 times/month
• Moderate persistent: Daily symptoms, nighttime awakenings >1 time/week but not nightly, daily SABA use
• Severe persistent: Symptoms throughout the day, nighttime awakenings often 7 times/week, SABA use several times/day

Stepwise Treatment Algorithm

Step 1: Intermittent Asthma

• Preferred: SABA as needed only (no daily controller medication required) 3, 2
• Albuterol/salbutamol 2 puffs as needed for symptom relief 1
• Critical monitoring: If SABA use exceeds 2 days/week (excluding exercise-induced symptoms), this indicates inadequate control and need to step up to Step 2 3, 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose ICS daily (200-250 μg fluticasone propionate equivalent) 3, 1, 2
• This "standard daily dose" achieves 80-90% of maximum therapeutic benefit 4
• Alternative options (for patients unable/unwilling to use ICS): Leukotriene receptor antagonists (montelukast 10 mg once daily for adults, zafirlukast twice daily), cromolyn, or nedocromil 3
• Continue SABA as needed for symptom relief 3

Key advantage of montelukast: High compliance rates due to once-daily oral dosing, particularly useful in patients with adherence challenges to inhaled medications 3

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS (200-250 μg fluticasone equivalent) PLUS long-acting beta-agonist (LABA) 3, 1, 2
  • Example: Fluticasone/salmeterol 100/50 μg or 250/50 μg twice daily 5
• Alternative: Medium-dose ICS alone (>250-500 μg fluticasone equivalent) 3
• Second alternative: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 3

Evidence supporting ICS/LABA combination: Adding LABA to low-dose ICS provides superior asthma control compared to doubling or quadrupling the ICS dose, with improvements in FEV₁ that are twice as great (0.6-0.7 L vs 0.3 L) 6, 7, 8

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred: Medium-dose ICS (>250-500 μg fluticasone equivalent) PLUS LABA 3
  • Example: Fluticasone/salmeterol 250/50 μg twice daily 5
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 3

Step 5: Severe Persistent Asthma

• Preferred: High-dose ICS (>500 μg fluticasone equivalent) PLUS LABA 3
  • Example: Fluticasone/salmeterol 500/50 μg twice daily 5
• Consider adding: Omalizumab for patients with documented allergic asthma and elevated IgE 3

Step 6: Severe Refractory Asthma

• Preferred: High-dose ICS PLUS LABA PLUS oral corticosteroids 3
• Consider omalizumab for allergic patients 3

Critical Safety Warnings

LABA Monotherapy Prohibition

Never prescribe LABA as monotherapy for asthma—this increases risk of severe exacerbations and asthma-related deaths 3, 5. LABAs must always be combined with ICS in a single inhaler device 3, 5.

Monitoring for Inadequate Control

If SABA use exceeds 2 days/week for symptom relief (not counting pre-exercise use), or if more than 2 nighttime awakenings occur per month, step up therapy immediately 3, 1, 2. This pattern indicates inadequate asthma control and increased exacerbation risk 1.

Inhaled Corticosteroid Adverse Effects

• Oral candidiasis: Instruct patients to rinse mouth with water without swallowing after each ICS use 1, 5
• Growth monitoring: Assess growth velocity in pediatric patients regularly 5
• Bone density: Consider baseline and periodic bone mineral density assessment in patients on long-term high-dose ICS 3
• Ocular effects: Monitor for glaucoma and cataracts with long-term use; refer to ophthalmology if visual symptoms develop 3

Acute Exacerbation Management

Immediate Treatment

• High-dose SABA: Albuterol 5 mg or terbutaline 10 mg via nebulizer with oxygen, or 4-8 puffs via metered-dose inhaler with spacer 1
• Systemic corticosteroids: Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately (requires 6-12 hours for anti-inflammatory effect) 3, 1
• Ipratropium bromide: Add 0.5 mg nebulized to each SABA treatment for severe airflow obstruction 1

Reassessment and Escalation

• Measure peak expiratory flow 15-30 minutes after initial treatment 1
• Hospital admission criteria: Peak flow <33% predicted after initial nebulization, oxygen saturation <92% on room air, respiratory rate >25 breaths/min, heart rate >110 bpm, or inability to complete sentences in one breath 1, 2

Absolute Contraindications in Acute Asthma

Never administer sedatives—they are absolutely contraindicated and can cause respiratory depression 1

Post-Exacerbation Management

• Continue or increase ICS dose 1
• Prednisolone 30-60 mg daily for 1-3 weeks (no taper needed for courses <2 weeks) 3, 1
• Provide written asthma action plan and peak flow meter 1
• Follow-up within 24-48 hours with primary care 2

Special Considerations

Leukotriene Receptor Antagonists

Montelukast is particularly useful for 3, 9:

• Patients unable/unwilling to use inhaled medications
• Aspirin-sensitive asthma (though it does not prevent aspirin-induced bronchospasm) 9
• Exercise-induced bronchospasm as adjunctive therapy

Neuropsychiatric warning: Monitor for agitation, depression, suicidal thinking, hallucinations, or behavioral changes; discontinue if these occur 9

Allergen Immunotherapy

Consider subcutaneous allergen immunotherapy for Steps 2-4 in patients with documented allergic asthma 3

Environmental Control

Identify and minimize exposure to triggers including house dust mite, pets, pollens, tobacco smoke 3. All patients should be advised to avoid active and passive smoking 3

Stepping Down Therapy

Once asthma is well-controlled for at least 3 months, consider stepping down treatment 3, 2:

• Reduce ICS dose by 25-50% every 3 months 2
• Before stepping down, verify adherence, proper inhaler technique, and adequate environmental control 2
• Maintain close monitoring during step-down periods 3

Patient Education Requirements

Every patient must receive 3, 1, 2:

• Written asthma action plan with specific instructions for medication adjustments based on symptoms/peak flow 3, 1
• Training on proper inhaler technique (metered-dose inhaler with spacer is preferred initial device) 3
• Clear distinction between "controller" (daily preventive) and "reliever" (as-needed rescue) medications 2
• Peak flow meter with instructions on monitoring technique 1
• Recognition of worsening symptoms requiring medical attention 3