What are the common medications, doses, and indications for asthma treatment in patients with varying severity of asthma, including mild persistent, moderate, and severe asthma?

Common Asthma Medications, Doses, and Indications

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma, with treatment intensity stepped up based on severity using a combination of ICS with long-acting beta-agonists (LABA) for moderate-to-severe disease. 1, 2

Medications by Asthma Severity

Intermittent Asthma (Step 1)

• Short-acting beta-agonist (SABA) as needed for symptom relief 3, 1
• Alternative: As-needed low-dose ICS-formoterol (budesonide-formoterol 160/4.5 mcg, 1 inhalation as needed) significantly reduces moderate-to-severe exacerbations compared to SABA alone 4
• No daily controller medication required 3

Mild Persistent Asthma (Step 2)

• Preferred: Low-dose ICS (fluticasone 100 mcg, budesonide 200 mcg, or equivalent daily) 3, 1, 2
• Alternative options:
  • Leukotriene receptor antagonists (LTRA) as second-line with good compliance 2
  • Cromolyn, nedocromil, or sustained-release theophylline (serum concentration 5-15 mcg/mL) 3
• Plus SABA as needed for quick relief 3

Moderate Persistent Asthma (Step 3-4)

• Preferred: Low-to-medium dose ICS plus LABA (e.g., fluticasone 250 mcg + salmeterol 50 mcg twice daily) 3, 1, 5
• For patients ≥12 years, adding LABA to ICS is preferred over increasing ICS dose alone 2
• Alternative: Medium-dose ICS alone (another option for children <5 years) 3
• Step 4 options: Medium-dose ICS-LABA or adding long-acting muscarinic antagonist (LAMA) 2
• Triple therapy: ICS-LABA-LAMA combination can improve symptoms, lung function, and reduce exacerbations when uncontrolled on medium/high-dose ICS-LABA 4

Severe Persistent Asthma (Step 5-6)

• High-dose ICS plus LABA (e.g., fluticasone 500 mcg + salmeterol 50 mcg twice daily, maximum dose) 3, 1, 5
• Add oral corticosteroids if needed: Low-dose (≤7.5 mg/day prednisone equivalent) as last resort 4
• Biologic therapies for severe type 2 asthma with elevated eosinophils, FeNO, or IgE 6, 2, 4
• Add-on azithromycin: 250-500 mg three times weekly for 26-48 weeks may reduce exacerbations in persistent symptomatic asthma despite Step 5 treatment 4

Specific Dosing by Age

Adults and Adolescents ≥12 Years

• ICS-LABA combinations: 1 inhalation twice daily, approximately 12 hours apart 5
  • Fluticasone/salmeterol: 100/50,250/50, or 500/50 mcg strengths available
  • Maximum: 500/50 mcg twice daily 5

Children 4-11 Years

• Mild persistent: Fluticasone/salmeterol 100/50 mcg, 1 inhalation twice daily 5
• Lower ICS doses recommended (e.g., budesonide 200 mcg daily) 3

Critical Safety Warnings

LABA should NEVER be used as monotherapy for asthma due to increased risk of asthma-related death, exacerbations, and hospitalizations—always combine with ICS 2, 5

• Patients using ICS-LABA should not use additional LABA for any reason 5
• More than 1 inhalation twice daily of prescribed ICS-LABA strength is not recommended 5
• Rinse mouth with water after ICS use without swallowing to reduce oropharyngeal candidiasis risk 5

Exacerbation Management

Home Management

• Increase SABA use for immediate relief 3
• For budesonide-formoterol users: Take 1-2 additional inhalations (160/4.5 mcg strength), maximum 8 inhalations daily 4
• Short course oral corticosteroids for moderate-to-severe exacerbations 3, 2
• Doubling ICS dose is NOT effective 3

Emergency/Hospital Setting

• High-dose nebulized beta-agonists 1
• Oral/parenteral corticosteroids administered early (benefits occur 6-12 hours later) 7
• Add ipratropium for severe cases 1
• Oxygen to maintain saturation >90% 7

Monitoring and Adjustment

Increasing SABA use >2 times weekly or >2 nights monthly indicates inadequate control and need to intensify anti-inflammatory therapy 1, 2

• Schedule follow-up every 2-4 weeks after initiating therapy, then every 1-3 months once controlled 4
• Spirometry recommended at initial assessment and every 1-2 years after stabilization 3
• Step up therapy if uncontrolled after 2 weeks; step down when stable to find minimum effective dose 3

Special Considerations

Comorbidities

• Annual influenza vaccination for all patients with persistent asthma 3
• Evaluate and treat allergic rhinitis, sinusitis, GERD, and medication sensitivities when symptoms persist 3

Allergen Immunotherapy

• Subcutaneous immunotherapy may reduce ICS requirements and improve quality of life in adults 4
• House dust mite sublingual immunotherapy for sensitized adolescents/adults with FEV₁ >70% predicted may reduce symptoms and ICS dose 4

High-Risk Patients Requiring Intensive Monitoring

• Previous intubation or ICU admission for asthma 3, 4
• ≥2 hospitalizations or >3 ED visits in past year 3
• Using >2 canisters SABA monthly 3
• Not currently using ICS 4
• Difficulty perceiving airflow obstruction 3

Common pitfall: Do not delay ICS initiation in persistent asthma—early intervention improves outcomes. Patients using SABA >2 times weekly likely need controller therapy, not just as-needed treatment. 2