Asthma Medications with Treatment Dosing
Short-Acting Beta-Agonists (SABAs) - Quick Relief
Albuterol (Salbutamol)
Adult Dosing:
- Nebulizer solution: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1
- MDI (90 mcg/puff): 2 puffs as needed for symptom relief; for acute exacerbations, 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours 1
Pediatric Dosing:
- Nebulizer solution: 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15-0.3 mg/kg up to 10 mg every 1-4 hours as needed 1
- MDI: 4-8 puffs every 20 minutes for 3 doses, then every 1-4 hours as needed 1
Levalbuterol (R-albuterol)
Adult Dosing:
- Nebulizer solution: 1.25-2.5 mg every 20 minutes for 3 doses, then every 1-4 hours as needed 1
Pediatric Dosing:
- Nebulizer solution: 0.075 mg/kg (minimum 0.25 mg) every 20 minutes for 3 doses, then 0.15 mg/kg up to 5 mg every 1-4 hours 1
Albuterol/Budesonide Combination (As-Needed Reliever)
Adult Dosing:
- MDI: 180/160 mcg (two actuations of 90/80 mcg) as needed for symptom relief and exacerbation prevention 2, 3
- This combination addresses both bronchoconstriction and inflammation, reducing exacerbation risk compared to albuterol alone 2
Anticholinergics
Ipratropium Bromide
Adult Dosing:
- Nebulizer solution (0.25 mg/mL): 0.5 mg every 20 minutes for 3 doses, then every 2-4 hours as needed 1
- MDI (18 mcg/puff): 4-8 puffs as needed 1
Pediatric Dosing:
- Nebulizer solution: 0.25 mg every 20 minutes for 3 doses, then every 2-4 hours 1
Ipratropium with Albuterol
Adult Dosing:
- Nebulizer solution: 3 mL (0.5 mg ipratropium + 2.5 mg albuterol) every 20 minutes for 3 doses, then every 2-4 hours 1
Pediatric Dosing:
- Nebulizer solution: 1.5-3.0 mL every 20 minutes for 3 doses, then as needed 1
Inhaled Corticosteroids (ICS) - Long-Term Control
Beclomethasone
Adult Dosing:
- Low dose (HFA 40 or 80 mcg/puff): 80-240 mcg daily 1
- Medium dose: 240-480 mcg daily 1
- High dose: >480 mcg daily 1
Budesonide
Adult Dosing:
- Low dose (DPI 200 mcg/inhalation): 200-600 mcg daily 1
- Medium dose: 600-1,200 mcg daily 1
- High dose: >1,200 mcg daily 1
Fluticasone
Adult Dosing:
- Low dose (MDI 44,110, or 220 mcg/puff): 88-264 mcg daily 1
- Medium dose: 264-660 mcg daily 1
- High dose: >660 mcg daily 1
- Low dose (DPI 50,100, or 250 mcg/inhalation): 100-300 mcg daily 1
- Medium dose: 300-750 mcg daily 1
- High dose: >750 mcg daily 1
Systemic Corticosteroids - Acute Exacerbations
Prednisone/Prednisolone
Adult Dosing:
- Outpatient burst: 40-60 mg daily as single or 2 divided doses for 5-10 days without tapering 1, 4
- Severe exacerbations: 40-80 mg daily until PEF reaches 70% of predicted or personal best 4
- Hospital management: 30-60 mg daily, continuing until 2 days after control is established 1, 4
Pediatric Dosing:
- Outpatient burst: 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering 1, 4
- Severe exacerbations: 1-2 mg/kg/day (maximum 60 mg/day) until PEF reaches 70% of predicted 4
Critical Points:
- No tapering is necessary for courses less than 7-10 days, especially if patients are on inhaled corticosteroids 4
- Oral administration is equally effective as IV therapy when GI absorption is intact 4
- Higher doses have not shown additional benefit in severe exacerbations 4
Methylprednisolone
Adult Dosing:
- Oral: 40-80 mg/day in 1-2 divided doses until PEF reaches 70% of predicted 4
- IV: 125 mg (dose range 40-250 mg) for patients unable to tolerate oral medications 4
Pediatric Dosing:
- Oral: 0.25-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) 4
Hydrocortisone (IV)
Adult Dosing:
- IV: 200 mg immediately, then 200 mg every 6 hours for patients who are vomiting, severely ill, or unable to tolerate oral medications 1, 4
Pediatric Dosing:
- IV: 4-7 mg/kg every 8 hours 4
Systemic Beta-Agonists (Injected) - Severe Exacerbations
Epinephrine 1:1000
Adult Dosing:
- Subcutaneous: 0.3-0.5 mg every 20 minutes for 3 doses 1
Pediatric Dosing:
- Subcutaneous: 0.01 mg/kg up to 0.3-0.5 mg every 20 minutes for 3 doses 1
Terbutaline
Adult Dosing:
- Subcutaneous: 0.25 mg every 20 minutes for 3 doses 1
Pediatric Dosing:
- Subcutaneous: 0.01 mg/kg every 20 minutes for 3 doses, then every 2-6 hours as needed 1
Biologic Therapy
Dupilumab (for Moderate-to-Severe Asthma)
Adult and Pediatric ≥12 Years:
- Initial loading dose: 400 mg (two 200 mg injections) or 600 mg (two 300 mg injections) 5
- Maintenance: 200 mg every 2 weeks OR 300 mg every 2 weeks 5
- For oral corticosteroid-dependent asthma or co-morbid moderate-to-severe atopic dermatitis: 600 mg loading dose, then 300 mg every 2 weeks 5
Pediatric 6-11 Years:
- 15 to <30 kg: 300 mg every 4 weeks (no loading dose) 5
- ≥30 kg: 200 mg every 2 weeks (no loading dose) 5
Important Clinical Considerations
SABA Use:
- SABAs should be used as-needed only, not regularly scheduled 6, 7, 8
- Regular use increases airway hyper-responsiveness and is associated with decreased asthma control 6
- Excessive SABA use (>1 canister per month) indicates inadequate control and need for increased controller therapy 1
Systemic Corticosteroid Timing:
- Administer systemic corticosteroids early in moderate-to-severe exacerbations, as anti-inflammatory effects take 6-12 hours to become apparent 4
- Delayed administration is a documented factor in preventable asthma deaths 4
Route of Administration:
- Oral corticosteroids are equally effective as IV therapy and strongly preferred when GI function is intact 4
- IV route should be reserved for patients who are vomiting, severely ill, or unable to tolerate oral medications 4
Common Pitfalls to Avoid:
- Do not underdose systemic corticosteroids during acute exacerbations 4
- Do not taper short courses (<7-10 days) of corticosteroids, as this may lead to underdosing during the critical recovery period 4
- Do not use SABAs regularly as maintenance therapy; this masks inadequate control and increases exacerbation risk 6, 7
- Do not delay systemic corticosteroid administration in acute exacerbations 9