What asthma medications should be used, including their dosages and clinical indications?

Asthma Medications: Doses and Indications

Quick-Relief (Rescue) Medications

Short-Acting Beta-Agonists (SABAs)

Albuterol (Salbutamol)

• Adult dose: 2.5-5 mg nebulized every 20 minutes for 3 doses initially, then every 1-4 hours as needed for acute exacerbations 1
• Pediatric dose: 5 mg nebulized (half doses in very young children), can be repeated every 30 minutes if not improving 1
• MDI dose: 2 puffs via large volume spacer, repeat 10-20 times if no nebulizer available 1
• Indication: As-needed relief of acute bronchospasm; first-line treatment for acute exacerbations 1
• Critical caveat: Using more than one canister per month indicates need to increase daily long-term control therapy 1

Terbutaline

• Adult dose: 10 mg nebulized via oxygen-driven nebulizer 1
• Pediatric dose: 10 mg nebulized (half doses in very young children) 1
• Indication: Alternative to albuterol for acute bronchospasm 1

Combination ICS-SABA (Newer Option)

Albuterol-Budesonide Fixed-Dose Combination

• Adult dose: 180 μg albuterol/160 μg budesonide (two actuations of 90 μg/80 μg) as needed 2, 3
• Indication: As-needed treatment or prevention of bronchoconstriction AND to reduce exacerbation risk in patients ≥18 years with moderate-to-severe asthma 2, 4, 3
• Key advantage: Reduces severe exacerbation risk by 26% compared to albuterol alone when used as rescue therapy 3
• Important note: NOT indicated for maintenance therapy or single maintenance and reliever therapy (SMART) 4

Anticholinergics

Ipratropium Bromide

• Adult dose: 0.5 mg nebulized every 6 hours, add to beta-agonist if patient not improving after 15-30 minutes 1
• Pediatric dose: 100 μg (0.1 mg) nebulized every 6 hours 1
• Indication: Adjunct to beta-agonists in moderate-to-severe acute exacerbations 1

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Systemic Corticosteroids for Acute Exacerbations

Oral Corticosteroids (Preferred Route)

Prednisone/Prednisolone

• Adult dose: 40-60 mg daily as single morning dose or in 2 divided doses for 5-10 days without tapering 5
• Severe exacerbations: 40-80 mg daily until peak expiratory flow reaches 70% of predicted 5
• Pediatric dose: 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days without tapering 5
• Indication: All moderate-to-severe asthma exacerbations; patients not responding to initial bronchodilator therapy 5
• Critical timing: Administer within 1 hour of emergency department presentation; effects take 6-12 hours to become apparent 5
• No tapering needed: For courses <7-10 days, especially if patient on inhaled corticosteroids 5

Intravenous Corticosteroids (When Oral Not Tolerated)

Hydrocortisone

• Adult dose: 200 mg IV immediately, then 200 mg every 6 hours 1, 5
• Pediatric dose: 4 mg/kg IV as initial dose 5
• Indication: Patients vomiting, severely ill, or unable to tolerate oral medications 1, 5

Methylprednisolone

• Adult dose: 40-80 mg/day IV in divided doses until PEF reaches 70% of predicted 5
• Alternative: 125 mg IV (dose range 40-250 mg) 5
• Pediatric dose: 0.25-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) 5
• Indication: Alternative to hydrocortisone when IV route necessary 5

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Long-Term Controller Medications

Inhaled Corticosteroids (ICS) - Most Effective Anti-Inflammatory

Budesonide (Nebulized)

• Indication: Maintenance treatment of asthma; most effective medication for treating underlying inflammation 1, 2
• Dosing: Varies by severity (low, medium, high dose ranges) - see stepwise approach 1
• Critical note: Required for all patients with persistent asthma (mild, moderate, or severe) 1

Stepwise Approach to Daily Controller Therapy

Step 1 (Mild Intermittent):

• No daily medication needed 1
• Short-acting beta-agonist as needed only 1

Step 2 (Mild Persistent):

• Preferred: Low-dose inhaled corticosteroids 1
• Alternatives: Cromolyn, leukotriene modifier, nedocromil (except children <5 years), or sustained-release theophylline to serum concentration 5-15 mcg/mL 1

Step 3 (Moderate Persistent):

• Preferred: Low-to-medium-dose inhaled corticosteroids PLUS long-acting inhaled beta-agonist 1
• Alternative preferred for children <5 years: Medium-dose inhaled corticosteroids alone 1

Step 4 (Severe Persistent):

• High-dose inhaled corticosteroids PLUS long-acting inhaled beta-agonist 1
• Add oral corticosteroids if needed 1

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Adjunctive Therapy for Life-Threatening Asthma

Aminophylline (Reserved for Severe Cases Only)

Dosing:

• Loading dose: 5 mg/kg IV over 20 minutes 1, 6
• Maintenance infusion: 0.5-0.7 mg/kg/hour 6
• CRITICAL WARNING: Omit loading dose if patient already taking oral theophyllines to avoid life-threatening toxicity 6

Indication:

• Only for life-threatening features or failure to improve with nebulized beta-agonists and systemic corticosteroids 6
• Requires continuous monitoring of serum theophylline levels 6

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Critical Clinical Pitfalls to Avoid

• Never delay systemic corticosteroids in moderate-to-severe exacerbations; underuse is a documented cause of preventable asthma deaths 1
• Do not underdose oral steroids in acute exacerbations; minimum effective dose is 30-60 mg daily for adults 5
• Do not taper short courses (<7-10 days) of corticosteroids; this is unnecessary and may lead to underdosing 5
• Monitor SABA overuse as a marker of poor control; >1 canister/month requires escalation of controller therapy 1
• Recognize paradoxical bronchospasm with beta-agonist inhalers; consider ipratropium as alternative rescue medication if this occurs 7
• Oral corticosteroids are equally effective as IV when GI absorption intact; IV route is unnecessarily invasive 5