What is the recommended approach for managing asthma in patients with variable severity?

Asthma Management in Patients with Variable Severity

Manage asthma using a stepwise approach that adjusts treatment intensity based on ongoing assessment of control, with the primary goal of achieving minimal symptoms, normal activity, and preventing exacerbations through regular monitoring and treatment adjustments every 2-6 weeks until control is achieved, then every 1-6 months thereafter. 1

Initial Assessment and Classification

Confirm the diagnosis with spirometry demonstrating reversible airflow obstruction (≥12% and ≥200 mL improvement in FEV1 after bronchodilator) before initiating long-term therapy. 2 Classify initial severity by assessing two critical domains:

Impairment domain:

• Frequency of daytime symptoms and nighttime awakenings 1, 2
• Limitation of normal activities 1
• Short-acting beta-agonist (SABA) use frequency (>2 days/week indicates need for controller therapy) 1, 3
• Lung function (FEV1 or peak expiratory flow) 1

Risk domain:

• History of exacerbations requiring oral corticosteroids, emergency department visits, or hospitalizations 1, 2
• Progressive loss of lung function 1

Identify comorbidities that impede control: rhinitis, sinusitis, GERD, obesity, obstructive sleep apnea, stress, and depression. 1 Test for allergen sensitivities using skin or in vitro testing in patients with persistent asthma requiring daily medication. 2

Stepwise Treatment Algorithm

Step 1 (Intermittent asthma):

• SABA as needed only; no daily controller medication required 3

Step 2 (Mild persistent):

• Low-dose inhaled corticosteroid (ICS) as preferred controller (≤800 μg/day beclomethasone equivalent) 2, 3
• SABA as needed for symptom relief 3

Step 3 (Moderate persistent):

• Low-dose ICS plus long-acting beta-agonist (LABA) combination as preferred therapy 2, 3
• Alternative: Medium-dose ICS alone 3

Step 4-6 (Severe persistent):

• High-dose ICS-LABA combination 3
• Consider adding long-acting muscarinic antagonist (triple therapy) 2
• May require oral corticosteroids for control 1

Use metered-dose inhalers with spacer devices as the preferred delivery system; spacers reduce oropharyngeal deposition and improve lung delivery, particularly for patients with coordination difficulties. 3

Monitoring and Adjusting Treatment

Schedule follow-up visits based on control status:

• Every 2-6 weeks when initiating therapy or stepping up treatment to achieve control 1
• Every 1-6 months once control is achieved, with frequency depending on treatment step and duration of control 1
• Every 3 months when considering stepping down therapy 1

At every visit, assess four critical elements:

• Asthma control using validated tools (Asthma Control Test or Asthma Control Questionnaire) 2, 4
• Inhaler technique (inadequate technique is a primary cause of treatment failure) 2, 3
• Adherence to the written asthma action plan 1
• Patient concerns and barriers to adherence 1, 2

Perform spirometry at initial assessment, after treatment initiation when symptoms stabilize, during progressive loss of control, and at least every 1-2 years (more frequently if not well-controlled). 1, 2 Low FEV1 indicates both current impairment and increased risk for future exacerbations. 1

Patient Self-Monitoring

Instruct all patients to monitor asthma control ongoing using either symptom monitoring or peak flow monitoring—evidence shows similar benefits for most patients. 1, 2 Consider daily peak flow monitoring specifically for patients with moderate-to-severe persistent asthma, history of severe exacerbations, or poor perception of airway obstruction. 1

Teach patients to recognize inadequate control:

• Symptoms occurring >2 days per week 1
• Nighttime awakenings due to asthma 1
• SABA use >2 days per week (excluding pre-exercise use) 1
• Any limitation in normal activities 1
• Peak flow <80% of personal best 2

Written Asthma Action Plan

Provide every patient with a written action plan that includes: 1, 2

Daily management instructions:

• Which long-term controller medications to take daily 1
• Environmental control measures specific to identified triggers 1

Instructions for worsening asthma:

• Specific signs, symptoms, and peak flow measurements indicating worsening 1
• How to adjust medications in response (note: doubling ICS dose at home is not effective) 1
• When to seek immediate medical care 1

Written action plans are particularly critical for patients with moderate-to-severe persistent asthma (Steps 4-6), history of severe exacerbations, or poorly controlled asthma. 1

Patient Education Essentials

Teach the fundamental difference between medication types:

• Long-term controllers (ICS) prevent symptoms through anti-inflammatory effects, must be taken daily, and do not provide quick relief 1, 3
• Quick-relief medications (SABA) relax airway muscles for prompt symptom relief but do not provide long-term control 1, 3

Verify proper inhaler technique at every visit by having the patient demonstrate their technique. 2, 3 Instruct patients to rinse mouth with water after ICS use to reduce oral candidiasis risk. 3, 5

Identify and reduce exposure to specific triggers based on testing results and history. 2 Address tobacco smoke exposure, allergens (house dust mite, cockroach, animal dander, mold), and occupational sensitizers. 2

Goals of Therapy

Reduce impairment:

• Prevent chronic troublesome symptoms (coughing, breathlessness) 1
• Require infrequent SABA use (≤2 days/week, excluding exercise prevention) 1
• Maintain normal or near-normal pulmonary function 1
• Maintain normal activity levels including exercise, work, and school attendance 1

Reduce risk:

• Prevent recurrent exacerbations and minimize emergency department visits or hospitalizations 1
• Prevent loss of lung function; in children, prevent reduced lung growth 1
• Provide optimal pharmacotherapy with minimal adverse effects 1

Common Pitfalls to Avoid

Never use sedatives during acute exacerbations—this is contraindicated and dangerous. 2 Do not prescribe antibiotics unless bacterial infection is confirmed; they are overused without evidence of benefit in asthma exacerbations. 2 Patients using ICS-LABA combinations should not use additional LABA for any reason. 5 Recognize that LABA monotherapy without ICS is associated with increased risk of asthma-related death and should never be used. 5

For patients with difficult-to-treat asthma uncontrolled despite adherence to high-dose ICS-LABA, confirm the diagnosis, address modifiable factors and comorbidities (particularly poor adherence, unrecognized allergens, GERD, psychological factors), and consider adding a long-acting muscarinic agent or leukotriene receptor antagonist before escalating to biologic therapies. 6, 7