What are the guidelines for managing asthma in patients, particularly regarding medication and treatment plans?

Asthma Management Guidelines

Core Treatment Principles

All asthma patients should receive inhaled corticosteroid (ICS)-based therapy from the outset, with short-acting beta-2 agonists (SABA) alone no longer recommended as monotherapy. 1

The cornerstone of asthma pharmacotherapy is ICS combined with short-acting or fast-acting beta agonists, with treatment intensity adjusted in a stepwise fashion based on disease severity and control. 1 The use of SABA alone as a symptom reliever in patients not using regular ICS is explicitly no longer recommended. 2

Stepwise Treatment Algorithm

Step 1: Mild Intermittent Asthma

• As-needed low-dose ICS-formoterol is the preferred treatment for patients with occasional transient daytime symptoms (<2 times/month, lasting hours), no nocturnal symptoms, no risk of exacerbations, and FEV1 >80% predicted. 3
• Albuterol as needed is acceptable only when combined with ICS therapy, not as monotherapy. 1, 4

Step 2: Mild Persistent Asthma

• As-needed low-dose ICS-formoterol is recommended and significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy. 3
• Alternatively, daily low-dose ICS is the preferred long-term controller medication. 1
• Budesonide is the preferred ICS formulation due to the most extensive safety data, though other ICS formulations are acceptable if already providing good control. 1, 4

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta-2 agonist (LABA) is the preferred controller treatment. 1
• ICS-LABA demonstrates synergistic anti-inflammatory and anti-asthmatic effects, achieving efficacy equivalent to or better than doubling the ICS dose. 3
• This combination improves patient adherence and reduces high-dose ICS-related adverse effects. 3

Step 4: Severe Persistent Asthma

• High-dose ICS plus LABA is required. 1
• Triple combination inhalers (ICS-LABA-LAMA) can be prescribed to improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium- or high-dose ICS-LABA. 3

Step 5: Severe Uncontrolled Asthma

• Add-on treatments should be initiated before phenotype-specific biologics. 1, 2
• For adult patients with persistent symptomatic asthma despite step 5 treatment, add-on low-dose azithromycin therapy (250-500 mg/day, three times weekly for 26-48 weeks) may reduce exacerbations. 3
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as the last choice for adults with severe asthma. 3
• Biologic agents are indicated for severe type 2 asthma when appropriate. 3, 2

Acute Severe Asthma Management

Recognition of Severity

• Severe features requiring immediate treatment include: inability to complete sentences in one breath, respiratory rate >25 breaths/min, heart rate >110 beats/min, and peak expiratory flow (PEF) <50% predicted or personal best. 4
• Life-threatening features include: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma, or severe hypoxia (PaO2 <8 kPa despite oxygen). 4

Immediate Treatment Protocol

• Administer high-dose nebulized beta-agonists immediately: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer. 1, 4
• Provide high-flow oxygen 40-60% to maintain SpO2 >92%. 5
• Administer systemic corticosteroids immediately: prednisolone 30-60 mg orally or IV hydrocortisone 200 mg. 1, 5, 4
• For life-threatening features, add ipratropium 0.5 mg to nebulizer treatments plus IV aminophylline or IV salbutamol/terbutaline. 1

Critical Contraindications

• Sedation is absolutely contraindicated in acute asthma. 1, 4
• Antibiotics should only be given if bacterial infection is confirmed. 1, 4

Corticosteroid Dosing for Acute Exacerbations

Adult Dosing

• Prednisone 40-60 mg daily as a single morning dose or in 2 divided doses for 5-10 days without tapering. 5
• For severe exacerbations requiring hospitalization, 40-80 mg/day until PEF reaches 70% of predicted or personal best. 5
• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact. 5

Pediatric Dosing

• Prednisone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering. 5
• Calculate dose based on ideal body weight rather than actual weight in overweight children to avoid excessive steroid exposure. 5

Duration and Tapering

• For courses lasting 5-10 days, no tapering is necessary, especially if patients are concurrently taking inhaled corticosteroids. 5
• Treatment should continue until PEF reaches at least 70% of predicted or personal best. 5
• Systemic corticosteroids should be administered within 1 hour of emergency department presentation for all moderate-to-severe exacerbations. 5

Hospital Discharge Criteria

Patients should not be discharged until: 1

• PEF is >75% of predicted/best
• Diurnal variability <25%
• Nocturnal symptoms have resolved

All patients discharged after acute exacerbation must receive: 1

• Prednisolone 30 mg daily or more for 1-3 weeks according to written action plan
• Inhaled corticosteroids at higher dosage than before admission (started at least 48 hours before discharge)
• Peak flow meter with written self-management plan
• Follow-up with primary care within 1 week and respiratory specialist within 4 weeks

Monitoring and Follow-Up

• Follow-up visits should be scheduled every 2-4 weeks after initial therapy, then every 1-3 months if there is a response. 3
• Step down therapy after prolonged control; step up if inadequately controlled. 1
• Regular training in correct inhaler technique is essential for optimal asthma control. 3
• All patients should have written action plans and peak flow meters. 1

Special Populations: Pregnancy

• Budesonide is the preferred ICS during pregnancy with the most reassuring safety data, though other ICS formulations may be continued if providing good control. 1
• Albuterol is the preferred SABA with extensive safety data in pregnancy. 1

Critical Pitfalls to Avoid

• Never use SABA monotherapy without ICS in any asthma patient, as this is associated with poor outcomes. 1, 2
• Do not delay systemic corticosteroids during acute exacerbations, as anti-inflammatory effects take 6-12 hours to become apparent. 5
• Do not underdose systemic corticosteroids, as this is a documented cause of preventable asthma deaths. 5
• Do not taper short courses (<7-10 days) of corticosteroids, as this is unnecessary and may lead to underdosing during the critical recovery period. 5
• Patients with persistent symptoms despite correct inhalation technique and adherence to Step 4 treatment should be referred to asthma specialists. 3