What is the first line therapy for a patient with mild to moderate persistent asthma?

First-Line Therapy for Mild to Moderate Persistent Asthma

Low-dose inhaled corticosteroids (ICS) administered twice daily are the foundation and preferred first-line controller medication for all patients with mild to moderate persistent asthma. 1

Recommended Initial Regimens

Start with one of these low-dose ICS options:

• Fluticasone propionate 100-250 mcg/day (divided twice daily) 1
• Budesonide 200-400 mcg/day (divided twice daily) 1
• Beclomethasone dipropionate 200-500 mcg/day (divided twice daily) 1

These low doses provide 80-90% of maximum therapeutic benefit with minimal systemic adverse effects. 2 ICS are superior to all other single long-term controller medications including leukotriene modifiers, theophylline, or cromones. 1, 2

Essential Delivery Technique

• Always prescribe a spacer or valved holding chamber with metered-dose inhalers to increase lung deposition and reduce oropharyngeal side effects like thrush. 1
• Instruct patients to rinse mouth and spit after each inhalation to further minimize local adverse effects. 1
• Verify proper inhaler technique before considering treatment failure or dose escalation. 1

Add Short-Acting Beta-Agonist for Rescue

• Combine ICS with as-needed short-acting beta-agonist (SABA) for quick symptom relief. 1
• If SABA use exceeds 2 days/week (excluding exercise prevention), this indicates inadequate control requiring treatment intensification. 2

When to Step Up Therapy (Moderate Persistent Asthma)

If asthma remains uncontrolled after 2-6 weeks on low-dose ICS alone:

• Add a long-acting beta-agonist (LABA) to low-dose ICS rather than increasing ICS dose alone. 1, 3 This combination provides greater improvement in lung function, symptoms, and exacerbation reduction compared to doubling ICS dose. 2
• The preferred combination for moderate persistent asthma is low-to-medium-dose ICS plus LABA, which demonstrates superior control with improved outcomes. 3
• LABAs must NEVER be used as monotherapy due to increased risk of severe exacerbations and asthma-related deaths—always combine with ICS in a single inhaler or as separate inhalers. 1, 3, 2

Alternative Step-Up Options (Less Preferred)

• Low-to-medium-dose ICS plus leukotriene modifier (e.g., montelukast) is an alternative but inferior to ICS/LABA. 3, 2
• Low-to-medium-dose ICS plus theophylline is the least preferred option due to side effect profile and need for serum monitoring. 3, 2

Monitoring and Follow-Up

• Assess treatment response within 2-6 weeks of initiating therapy. 1
• Once asthma control is sustained for 2-4 months, step down therapy to the minimum dose required to maintain control. 1, 2
• Continue monitoring for at least 3 months of stable control before considering further dose reduction. 1

Common Pitfalls to Avoid

• Do not start with high-dose ICS—it provides no clinically meaningful advantage over low-dose ICS, with only a 5% improvement in FEV1. 1
• Do not increase ICS dose short-term for worsening symptoms in adherent patients with mild-moderate asthma, as this provides no benefit. 1
• Smokers have decreased responsiveness to steroids due to persistent irritation. 1
• Poor inhaler technique is a common cause of apparent treatment failure—always verify technique before escalating therapy. 1

Special Considerations for Children

• For children 5-11 years with mild persistent asthma, use age-appropriate low-dose ICS (e.g., fluticasone 100 mcg twice daily). 2
• For children younger than 5 years with moderate persistent asthma, medium-dose ICS as monotherapy is preferred. 3