Treatment of Seasonal Asthma
For patients with seasonal asthma, initiate daily inhaled corticosteroid (ICS) therapy 2-4 weeks before the anticipated pollen season and continue throughout the season, with as-needed short-acting beta-agonists for symptom relief. 1
Initial Treatment Strategy
Start low-to-medium dose ICS as controller therapy before the season begins, as this approach has been specifically recommended for patients with asthma symptoms only during certain seasons (e.g., seasonal pollen allergens) who have intermittent asthma the rest of the year 1
Begin treatment 2 weeks in advance of the expected season and maintain throughout the entire pollen exposure period 2
Close monitoring for 2-6 weeks after discontinuing seasonal therapy is essential to ensure sustained asthma control 1
Medication Selection
First-Line Controller Therapy
ICS monotherapy is the foundation of treatment for seasonal asthma, as inhaled corticosteroids are the most effective medication class for controlling asthma symptoms 3, 4
For patients requiring Step 2 treatment, as-needed low-dose ICS-formoterol is recommended and significantly reduces moderate-to-severe exacerbations compared with short-acting beta-agonist monotherapy 5
Medium-dose ICS-LABA combinations should be used for moderate persistent seasonal asthma, as they demonstrate synergistic anti-inflammatory effects and achieve efficacy equivalent to or better than doubling the ICS dose 5
Reliever Medications
Short-acting beta-agonists remain the preferred reliever medication for acute symptom relief during the season 6
As-needed low-dose ICS-formoterol can serve dual roles as both maintenance and reliever therapy, which is particularly effective in reducing exacerbations 5
Alternative and Adjunctive Options
When ICS Alone Is Insufficient
Add a leukotriene receptor antagonist (montelukast) if symptoms persist, though recognize that intranasal corticosteroids are more effective than montelukast for seasonal allergic rhinitis symptoms that often accompany seasonal asthma 1
Montelukast at 10 mg once daily can be used as an adjunct, particularly in patients with concurrent seasonal allergic rhinitis, though it should not replace ICS as first-line therapy 7
For Patients with Allergic Sensitization
Consider allergen immunotherapy (AIT) for children and adults with confirmed pollen sensitization, as 3 years of therapy reduces the risk of developing persistent asthma by 36% in mono-sensitized patients 1
Pre-seasonal or co-seasonal sublingual immunotherapy (SLIT) should be initiated at least 8 weeks before pollen season for optimal clinical efficacy, with 4 months of preseasonal treatment being optimal 1
Subcutaneous immunotherapy may reduce ICS requirements and improve asthma-specific quality of life in adults with allergic asthma 5
Treatment Escalation Algorithm
Step 1 (Mild Intermittent Seasonal Asthma)
- As-needed low-dose ICS-formoterol for patients with occasional symptoms (<2 times/month, no nocturnal symptoms, FEV1 >80% predicted) 5
Step 2 (Mild Persistent Seasonal Asthma)
Step 3 (Moderate Persistent Seasonal Asthma)
- Medium-dose ICS-LABA combination therapy as the preferred option 5
- Consider adding leukotriene receptor antagonist if symptoms remain uncontrolled 2
Step 4 (Severe Seasonal Asthma)
- High-dose ICS-LABA with consideration for triple therapy (ICS-LABA-LAMA) if symptoms persist 5
- Refer to asthma specialist for evaluation of biologic therapy if uncontrolled despite Step 4 treatment 5
Critical Pitfalls to Avoid
Do not rely on SABA monotherapy for patients with recurrent seasonal symptoms, as this increases exacerbation risk and does not address underlying inflammation 1, 5
Avoid oral corticosteroids for routine seasonal asthma management; reserve them only for severe exacerbations or very poorly controlled disease 1
Do not discontinue ICS therapy abruptly at season's end without close monitoring, as this may lead to loss of control 1
Do not assume combination therapy is always superior to ICS monotherapy for initial treatment; start with ICS alone and add agents only if needed 4
Avoid starting immunotherapy during active pollen season; it must be initiated at least 8 weeks before anticipated exposure for efficacy 1
Monitoring and Follow-Up
Schedule follow-up visits every 2-4 weeks after initiating therapy, then every 1-3 months if there is adequate response 5
Verify correct inhaler technique at each visit, as improper technique is a common cause of treatment failure 5
Reassess 2-6 weeks after discontinuing seasonal therapy to confirm sustained control and determine if year-round treatment is needed 1
Consider stepping down therapy once asthma is well controlled for at least 3 months, reducing ICS dose by 25-50% every 3 months to identify minimum effective therapy 1