What are the steps for asthma management?

From the Guidelines

The stepwise approach to asthma management involves progressively intensifying treatment based on symptom control, with the goal of minimizing morbidity, mortality, and improving quality of life. For Step 1 (intermittent asthma), as-needed short-acting beta-agonists (SABA) like albuterol 2 puffs every 4-6 hours as needed are recommended 1. Step 2 adds a low-dose inhaled corticosteroid (ICS) such as fluticasone 88mcg 1-2 puffs twice daily. Step 3 increases to medium-dose ICS or combines low-dose ICS with a long-acting beta-agonist (LABA) like fluticasone/salmeterol 100/50mcg 1 puff twice daily. Step 4 uses medium-dose ICS/LABA combinations. Step 5 adds a long-acting muscarinic antagonist (LAMA) like tiotropium 2.5mcg 2 puffs once daily or biologics for specific phenotypes. Step 6 incorporates high-dose ICS/LABA plus oral corticosteroids like prednisone. At each step, patients should continue using rescue inhalers as needed. Regular reassessment every 2-6 months is essential, stepping up if control is inadequate or stepping down if control is maintained for 3+ months, as recommended by the most recent guidelines 1.

Key Considerations

• The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs 1.
• Inhaled corticosteroids (ICSs) continue as preferred long-term control therapy for all ages, with a combination of long-acting beta2-agonist (LABA) and ICS presented as an equally preferred option for patients 5 years of age or older 1.
• Omalizumab is recommended for consideration for youths 12 years of age who have allergies or for adults who require step 5 or 6 care (severe asthma) 1.
• The treatment intensity should match symptom severity and frequency to minimize medication side effects while maximizing control, with the goal of achieving optimal asthma control, which may require a progressive increase in inhaled corticosteroid/long-acting beta2 agonist therapy 1.

Treatment Steps

• Step 1: Intermittent asthma - as-needed SABA
• Step 2: Mild persistent asthma - low-dose ICS
• Step 3: Moderate persistent asthma - medium-dose ICS or low-dose ICS + LABA
• Step 4: Moderate persistent asthma - medium-dose ICS/LABA
• Step 5: Severe persistent asthma - high-dose ICS/LABA + LAMA or biologics
• Step 6: Severe persistent asthma - high-dose ICS/LABA + oral corticosteroids

Regular Reassessment

Regular reassessment every 2-6 months is essential to step up if control is inadequate or step down if control is maintained for 3+ months, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

For oral inhalation only. • Treatment of asthma in patients aged 12 years and older: 1 inhalation of Wixela Inhub® 100/50, Wixela Inhub® 250/50, or Wixela Inhub® 500/50 twice daily. Starting dosage is based on asthma severity. • Treatment of asthma in patients aged 4 to 11 years: 1 inhalation of Wixela Inhub® 100/50 twice daily.

The treatment of asthma is based on the severity of the disease, with different dosages of Wixela Inhub® recommended for patients aged 12 years and older and those aged 4 to 11 years. The stepwise approach for asthma treatment is not explicitly outlined in the provided drug label, but it implies that the treatment should be adjusted according to the patient's response and the severity of their asthma. Key points to consider include:

• Starting dosage: based on asthma severity
• Age: different recommendations for patients aged 4 to 11 years and those aged 12 years and older
• Dosage adjustment: implied to be necessary based on patient response and asthma severity 2

From the Research

Asthma Stepwise Approach

• The stepwise approach to asthma management involves a gradual increase in treatment intensity based on the severity of symptoms and the patient's response to treatment 3.
• The approach typically starts with mild intermittent asthma, where treatment is stepped up to more intensive regimens as needed to achieve and maintain control of symptoms 3.

Step 1: Mild Intermittent Asthma

• For patients with mild intermittent asthma, as-needed low-dose ICS-formoterol is recommended 3.
• This treatment is suitable for patients with limited to occasional transient daytime symptoms, no nocturnal symptoms, no risk of exacerbations, and FEV1 > 80% predicted 3.

Step 2: Mild Persistent Asthma

• For patients with mild persistent asthma, as-needed low-dose ICS-formoterol is also recommended 3.
• This treatment significantly reduces moderate-to-severe exacerbations compared with short-acting β2-agonist (SABA) monotherapy 3.

Step 3-5: Moderate to Severe Asthma

• For patients with moderate to severe asthma, treatment involves a combination of inhaled corticosteroids (ICS) and long-acting β2-agonists (LABA) 4, 5.
• The combination of ICS and LABA demonstrates synergistic anti-inflammatory and anti-asthmatic effects, achieving efficacy equivalent to or better than doubling the ICS dose 4, 5.
• Triple combination inhalers can be prescribed to improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium- or high-dose of ICS-LABA 3.

Severe Asthma

• Severe asthma is uncontrolled asthma despite prescribing 3 or more months of continuous standardized use of a medium- or high-dose ICS-LABA and has been treated for comorbidity diseases and avoid environmental stimulus, or worsening after stepping down to a lower dose ICS-LABA 3.
• Patients with severe type 2 asthma can be treated with biologic therapy, and those who had a good response to type 2-targeted biologic therapies can prioritize decrease or stop maintenance OCS therapy, but should not completely stop maintenance therapy with ICS-LABA 3.