What are the guidelines for treating asthma in patients with varying levels of severity and control?

Guidelines for Asthma Treatment

Initial Assessment and Classification

Assess asthma severity before initiating therapy using two domains: impairment (current symptoms and functional limitations) and risk (likelihood of exacerbations or lung function decline), then use ongoing control assessments to adjust treatment. 1

Severity Classification Parameters

Classify severity using these specific measures before starting treatment:

• Symptom frequency: Count daytime symptoms per week (≤2 days/week = intermittent; >2 days/week but not daily = mild persistent; daily = moderate persistent; throughout the day = severe persistent) 1
• Nighttime awakenings: Frequency per month (≤2/month = intermittent; 3-4/month = mild persistent; >1/week = moderate persistent; nightly = severe persistent) 1
• SABA use for symptom relief: Days per week requiring rescue medication, excluding exercise prevention (≤2 days/week = intermittent; >2 days/week but not daily = mild persistent; daily = moderate persistent; several times daily = severe persistent) 1
• Activity limitation: None, minor, some, or extreme interference with normal activities 1
• Lung function: FEV1 percentage predicted and FEV1/FVC ratio (>80% predicted with normal ratio = intermittent/mild; 60-80% predicted = moderate; <60% predicted = severe) 1
• Exacerbation history: Patients with ≥2 exacerbations requiring oral corticosteroids in the past year are classified as persistent asthma regardless of other impairment measures 1

Critical Distinction: Severity vs. Control

• Severity determines where to start treatment—assess this at initial presentation in patients not on long-term controllers 1
• Control determines how to adjust treatment—assess this at every subsequent visit once therapy is initiated 1

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Stepwise Treatment Approach by Severity

Mild Persistent Asthma

Initiate daily low-dose inhaled corticosteroids (ICS) as first-line controller therapy, combined with short-acting beta-agonist (SABA) for symptom relief. 2, 3

• Low-dose ICS is the most consistently effective anti-inflammatory therapy and improves asthma control more effectively than any other single long-term controller medication 2
• SABA should be used ≤2 days per week for symptom relief (not including exercise prevention); more frequent use indicates inadequate control requiring treatment intensification 1, 2

Moderate Persistent Asthma

Use either medium-dose ICS alone OR low-dose ICS combined with long-acting beta-agonist (LABA) as equally preferred options. 1, 2

• The combination ICS-LABA approach balances established beneficial effects with the increased risk of severe exacerbations (although uncommon) associated with daily LABA use 1
• Critical warning: LABAs must never be used as monotherapy due to increased risk of asthma-related death and hospitalization 4
• Patients using ICS-LABA combinations should not use additional LABA for any reason 4

Severe Persistent Asthma

Initiate high-dose ICS-LABA combination therapy, with consideration of adding omalizumab for patients aged ≥12 years with allergic asthma requiring step 5 or 6 care. 1, 3

• High-dose ICS plus LABA is the foundation therapy for severe disease 5
• Omalizumab targets type-2 inflammation and is indicated for moderate-to-severe or severe allergic asthma 3, 6
• Clinicians administering omalizumab must be prepared and equipped to identify and treat anaphylaxis 1

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Age-Specific Treatment Modifications

Children 4-11 Years

• Use ICS 100 mcg/50 mcg LABA twice daily for children not controlled on ICS alone 4
• Monitor growth velocity closely, as ICS may cause reduction in growth 4
• Titrate to the lowest effective strength to minimize systemic corticosteroid effects 4

Adolescents ≥12 Years and Adults

• Dosing is 1 inhalation twice daily, approximately 12 hours apart 4
• Maximum recommended dosage is ICS 500 mcg/LABA 50 mcg twice daily 4
• Improvement may occur within 30 minutes, but maximum benefit may require 1 week or longer 4

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Monitoring and Adjusting Therapy

Control Assessment Parameters

Assess control at every visit using the same domains as severity classification: symptoms, nighttime awakenings, SABA use, activity limitation, lung function, and exacerbations. 1, 3

• Well-controlled: Symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, SABA use ≤2 days/week, no interference with activities, FEV1 >80% predicted, 0-1 exacerbations/year 1
• Not well-controlled: Symptoms >2 days/week, nighttime awakenings 1-3 times/week, SABA use >2 days/week, some limitation of activities, FEV1 60-80% predicted, ≥2 exacerbations/year 1
• Very poorly controlled: Daily symptoms, nightly awakenings ≥4 times/week, SABA use several times daily, extreme activity limitation, FEV1 <60% predicted, ≥2 exacerbations/year 1

Follow-Up Schedule

• Every 2-6 weeks when initiating therapy or stepping up treatment 3, 5
• Every 1-6 months once control is achieved 3, 5
• Every 3 months if considering step-down therapy 3
• Perform spirometry at initial assessment, after treatment initiation, during progressive loss of control, and at least every 1-2 years 2, 3

Treatment Adjustment Algorithm

If control is inadequate after 2 weeks of therapy, replace current ICS-LABA strength with higher strength, add additional ICS, or initiate oral corticosteroids. 4

• Step up therapy when control is not achieved 1
• Step down therapy when control is maintained for at least 3 months to find the lowest effective dose 1
• Do not double ICS doses during exacerbations—this is ineffective; use oral corticosteroids instead 3

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Essential Non-Pharmacological Components

Patient Education and Self-Management

Provide a written asthma action plan to all patients with instructions for daily management, recognizing worsening asthma, increasing treatment, and seeking emergency care. 2, 3, 5

• Teach patients to recognize inadequate asthma control through either symptom monitoring or peak flow monitoring—evidence suggests benefits are similar 1
• Peak flow monitoring is particularly important for patients with moderate-severe asthma, history of severe exacerbations, or poor symptom perception 3
• Verify proper inhaler technique at every visit, as inadequate technique is a common cause of poor control 2, 3
• Instruct patients to rinse mouth with water after ICS inhalation without swallowing to reduce oropharyngeal candidiasis risk 4

Environmental Control and Comorbidity Management

Identify and reduce exposure to specific triggers using skin testing or specific IgE measurements for perennial allergens in patients with persistent asthma requiring daily medication. 1, 2

• Eliminate tobacco smoke exposure completely 2
• Address comorbidities that impede asthma management: gastroesophageal reflux disease, rhinitis, sinusitis, obstructive sleep apnea, obesity, stress, and depression 1, 6
• Substantially reducing allergen exposure (house dust mite, cockroach, animal dander, mold) may reduce inflammation, symptoms, and medication needs 2

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Treatment Goals

The primary goals are to minimize impairment (prevent chronic symptoms, require infrequent SABA use, maintain normal pulmonary function and activity levels) and reduce risk (prevent exacerbations, ED visits, hospitalizations, lung function decline, and medication adverse effects). 1

Specific Impairment Goals

• Prevent chronic and troublesome symptoms (coughing, breathlessness during day, night, or after exertion) 1
• Require SABA use ≤2 days per week for symptom relief 1
• Maintain near-normal pulmonary function 1
• Maintain normal activity levels including exercise, physical activity, school, and work attendance 1
• Meet patients' and families' expectations and satisfaction with asthma care 1

Specific Risk Goals

• Prevent recurrent exacerbations and minimize ED visits or hospitalizations 1
• Prevent loss of lung function; for children, prevent reduced lung growth 1
• Provide optimal pharmacotherapy with minimal or no adverse effects 1

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Common Pitfalls and How to Avoid Them

Underestimation of Poor Control

Both patients and physicians tend to underestimate symptom severity or overestimate control—39-70% of patients report well-controlled asthma despite experiencing moderate symptoms. 1

• Use validated tools like the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) at every visit 2, 3
• Do not rely solely on patient self-report of control 1

LABA Safety Concerns

Never prescribe LABA as monotherapy—this increases risk of asthma-related death and hospitalization. 4

• Always use LABA in fixed-dose combination with ICS 4
• Patients using ICS-LABA should not use additional LABA for any reason 4

Inadequate Inhaler Technique

Verify and correct inhaler technique at every visit, as this is a common cause of poor control. 2, 3

• Demonstrate proper technique and have patients demonstrate back 2
• Address this before escalating therapy for apparent poor control 2

Specialist Referral Indications

Refer to a specialist if patients have difficulty achieving or maintaining control, require multiple bursts of oral corticosteroids, experience exacerbations requiring hospitalization, or require step 4 care or higher. 5

• Consider referral when considering immunotherapy or omalizumab 5