What are the guidelines for treating a patient with asthma, including first-line and subsequent treatments?

Asthma Treatment Guidelines: First-Line and Stepwise Management

For newly diagnosed asthma in adults and adolescents ≥12 years, initiate treatment with low-dose inhaled corticosteroids (ICS) at 100-250 mcg of fluticasone propionate (or equivalent) twice daily, which provides 80-90% of maximum therapeutic benefit while minimizing systemic adverse effects. 1

Initial Assessment Before Treatment

Before initiating therapy, assess the following specific parameters:

• Symptom frequency: Daytime symptoms, nighttime awakenings, and interference with normal activity over the previous 2-4 weeks 1
• SABA use: Need for short-acting beta-agonist more than 2 days per week indicates inadequate control 1
• Exacerbation history: Previous episodes requiring oral corticosteroids, emergency department visits, or hospitalizations 1
• Objective lung function: Measure peak expiratory flow (PEF) or FEV1 to establish baseline 1

First-Line Treatment Algorithm

Step 1: Mild Intermittent Asthma

• As-needed short-acting β2-agonists (SABA) only: Albuterol 2 puffs as needed for symptoms 2, 1
• No daily controller medication required 2

Step 2: Mild to Moderate Persistent Asthma

• Low-dose ICS: Fluticasone propionate 100-250 mcg twice daily 1, 3
• Plus as-needed SABA: Albuterol 2 puffs for acute symptoms 1
• This "standard daily dose" achieves approximately 80-90% of maximum ICS benefit 3

Critical administration details:

• Use a spacer or valved holding chamber with metered-dose inhalers to reduce local side effects and improve drug delivery 1
• Rinse mouth with water and spit after each ICS dose to reduce oral candidiasis risk 1
• Verify inhaler technique at every visit, as poor technique is the most common cause of treatment failure 1

Step 3: Moderate Persistent Asthma (Not Controlled on Low-Dose ICS)

If asthma remains uncontrolled on low-dose ICS monotherapy, add a long-acting beta-agonist (LABA) rather than doubling the ICS dose. 4, 5

• Combination ICS/LABA: Fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily 1, 6
• This combination provides superior asthma control compared to doubling the ICS dose alone 4, 5
• The adjusted difference in morning PEF between combination therapy (52 L/min improvement) versus doubled ICS dose (36 L/min improvement) was 16.6 L/min (95% CI: 1.1-32.0) 4

Evidence supporting combination over dose escalation:

• Combination therapy increases symptom-free days by 49% versus 38% with doubled ICS dose (adjusted difference: 12.6% of days, 95% CI: 4.0-20.7) 4
• Adding salmeterol to low-dose ICS is more effective than increasing ICS dose and avoids systemic adverse effects of higher ICS doses 3, 7

Step 4: Severe Persistent Asthma

• High-dose ICS/LABA combination: Fluticasone/salmeterol 250/50 mcg or 500/50 mcg twice daily 1, 6
• Consider only after inadequate response to medium-dose combination therapy 1

Acute Exacerbation Management

Severity Assessment

Severe asthma features (immediate treatment required): 8, 2

• Cannot complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• PEF <50% of predicted or personal best

Life-threatening features (hospital admission mandatory): 8, 2

• PEF <33% of predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, exhaustion, confusion, or coma
• Normal or elevated PaCO2 (5-6 kPa) in a breathless patient
• Severe hypoxia: PaO2 <8 kPa despite oxygen therapy

Immediate Treatment Protocol

Begin simultaneously: 8, 2, 9

1. High-dose inhaled β2-agonists: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen, OR 4-12 puffs via MDI with spacer every 20-30 minutes for three doses 8, 9

2. Systemic corticosteroids immediately: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 8, 9

   • Early administration is critical as corticosteroids take 6-12 hours to manifest anti-inflammatory effects 9
   • Continue for 1-3 weeks (NOT the insufficient 5-6 day Medrol dose pack) 9

3. If life-threatening features present, add:

   • Ipratropium bromide 0.5 mg nebulized to each β-agonist treatment 8, 9
   • IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 mcg over 10 minutes 8
   • Do NOT give bolus aminophylline to patients already taking oral theophyllines 8

Hospital Admission Criteria

Admit immediately if: 8, 2

• Any life-threatening features present
• Severe features persist after initial treatment
• PEF remains <33% of predicted 15-30 minutes after nebulization

Lower threshold for admission if: 8

• Seen in afternoon/evening rather than earlier in day
• Recent onset of nocturnal symptoms or worsening symptoms
• Previous severe attacks, especially with rapid onset
• Concern over patient's assessment of severity
• Concern over social circumstances or relatives' ability to respond

Monitoring and Follow-Up

Early Reassessment

• Reassess 2-6 weeks after initiating treatment to evaluate asthma control 1
• Measure PEF or FEV1 to assess objective improvement 1
• Verify inhaler technique at every visit 1

Ongoing Management

• Patients with intermittent asthma: Evaluate once yearly 8
• Patients on controller agents: See at least twice yearly, as often as every 4 months 8
• Consider step-down therapy when stable for ≥3 months 8, 2

Post-Exacerbation Follow-Up

• Do not discharge from hospital until PEF >75% of predicted/personal best 2
• Follow-up within 24-48 hours after acute exacerbations 2
• Primary care follow-up within 1 week 9
• Respiratory specialist within 4 weeks 9

Essential Patient Education

All patients require: 2, 1

• Written asthma action plan with clear instructions for medication adjustment
• Understanding the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory agents)
• Recognition of worsening symptoms
• Peak flow meter with instructions on use
• Pre-arranged action steps based on symptoms/peak flow

Critical Pitfalls to Avoid

Never do the following: 2, 9

• Overreliance on bronchodilators without anti-inflammatory treatment
• Underestimating severity of exacerbations (failure to make objective measurements is the most common cause of fatal attacks)
• Using sedatives in acute asthma (contraindicated—can worsen respiratory depression)
• Delaying systemic corticosteroids during severe exacerbations
• Prescribing antibiotics without clear evidence of bacterial infection
• Discharging without ensuring adequate steroid duration (1-3 weeks, not 5-6 days)
• Using LABA monotherapy without ICS (increases risk of serious asthma-related events)
• Combining with additional LABA-containing medications (risk of overdose)

Monitor for long-term ICS adverse effects (>1 year of high-dose use): 1

• Bone mineral density (consider bone densitometry)
• Ocular complications (consider slit-lamp examination)
• Ensure adequate calcium and vitamin D intake
• Monitor growth in pediatric patients