Asthma Management Medications with Dosages
For adults with persistent asthma, low-dose inhaled corticosteroids (ICS) are the foundation of treatment, with specific dosing based on severity: fluticasone propionate 100-250 mcg/day or budesonide 200-400 mcg/day administered twice daily for mild persistent asthma, escalating to combination therapy with long-acting beta-agonists (LABA) for moderate to severe disease. 1, 2, 3
Step 1: Mild Intermittent Asthma
- Short-acting beta-agonist (SABA) as needed only 4
- Albuterol/salbutamol: 2 puffs every 4-6 hours as needed for symptoms 4
- No daily controller medication required 4
Step 2: Mild Persistent Asthma
Preferred First-Line Treatment
Alternative Options
Critical Administration Technique
- Always use a spacer or valved holding chamber with metered-dose inhalers 2, 3
- Rinse mouth and spit after each use to prevent oral thrush 2, 3
Step 3: Moderate Persistent Asthma
Preferred Treatment
Alternative Options
- Medium-dose ICS monotherapy (less effective than adding LABA) 1, 6
- Low-to-medium dose ICS plus leukotriene modifier 4, 1
SMART Protocol (Symbicort Maintenance and Reliever Therapy)
- Budesonide/formoterol can be used as both maintenance and rescue therapy for patients ≥12 years 1
- Maintenance: 2 inhalations twice daily 1
- Additional inhalations as needed for symptom relief (formoterol's rapid onset allows this approach) 1, 5
Step 4: Severe Persistent Asthma
Preferred Treatment
When Oral Corticosteroids Are Needed
- Add oral corticosteroids if not controlled on high-dose ICS/LABA 4, 1
- Prednisone: 1-2 mg/kg/day (generally not exceeding 60 mg/day) 4
- Use lowest possible dose, preferably alternate-day dosing 4
- Make persistent attempts to reduce systemic corticosteroids once control is achieved 4
Acute Exacerbations
Oral Corticosteroid Dosing
- Adults: 40-60 mg/day prednisone in one or two divided doses for 5-10 days 4
- Children: 1-2 mg/kg/day for 3-10 days 4
- Tapering is not necessary 4
- Inhaled corticosteroids are insufficient for moderate to severe exacerbations due to delayed onset of action 4
Critical Safety Warnings
LABA Monotherapy Prohibition
- LABAs should NEVER be used as monotherapy for asthma 4, 1, 3
- Always combine LABA with ICS to prevent increased risk of severe exacerbations and asthma-related deaths 4, 1, 3
- This warning applies to all ages and is based on FDA safety review 4
Monitoring and Reassessment
- Assess treatment response every 2-6 weeks initially 2, 3
- Verify proper inhaler technique before escalating therapy (poor technique is a common cause of apparent treatment failure) 2, 3
- Step down therapy after 2-4 months of sustained control to find minimum effective dose 2
Common Pitfalls to Avoid
Technique Errors
- Not using a spacer with MDIs reduces lung deposition and increases local side effects 2, 3
- Failing to rinse mouth after ICS use increases risk of oral candidiasis (occurs in ~9.5% of patients) 2
Dosing Errors
- Doubling ICS dose provides minimal additional benefit compared to adding LABA 1, 6
- Starting with high-dose ICS provides no clinically meaningful advantage over starting with low-dose ICS (only 5% improvement in FEV1) 3
- Increasing ICS dose short-term for worsening symptoms in adherent patients provides no benefit 3
Treatment Strategy Errors
- Using SABA more than 2 days per week for symptom relief indicates inadequate control and need for controller therapy 3
- Continuing high-dose ICS monotherapy when asthma remains uncontrolled after 2-6 weeks instead of adding LABA 3
- Not addressing environmental triggers and adherence before escalating therapy 1, 3
Specific Dosing Considerations by Age
Children 0-4 Years
- Low-dose fluticasone: ≤176 mcg/day total 2
- Medium-dose ICS monotherapy preferred (LABA lacks safety data in this age group) 1, 2
- Always use face mask that fits snugly over nose and mouth 2
Children 5-11 Years
- Low-dose fluticasone: 100-200 mcg/day total 2
- Medium-dose fluticasone: >200-500 mcg/day total 2
- Combination therapy extrapolated from adult studies (limited pediatric data) 4