What are the recommended treatment steps for asthma based on severity and control according to current guidelines?

Asthma Treatment Guidelines: Stepwise Approach Based on Severity and Control

Initiate treatment using a stepwise algorithm that matches medication intensity to asthma severity at diagnosis, then adjust therapy at every visit based on control status rather than severity, stepping up when control is inadequate and stepping down after 3 months of well-controlled asthma. 1, 2

Initial Classification of Asthma Severity (Before Treatment)

Classify severity using both impairment and risk domains to determine starting therapy 3, 2:

Impairment Domain Assessment

• Daytime symptoms: ≤2 days/week (intermittent), >2 days/week but not daily (mild persistent), daily (moderate persistent), or throughout the day (severe persistent) 3
• Nighttime awakenings: ≤2 times/month (intermittent), 3-4 times/month (mild persistent), >once/week but not nightly (moderate persistent), or often 7 times/week (severe persistent) 3
• SABA use for symptom control: ≤2 days/week (intermittent), >2 days/week but not daily (mild persistent), daily (moderate persistent), or several times/day (severe persistent) 3
• Activity interference: None (intermittent), minor limitation (mild persistent), some limitation (moderate persistent), or extremely limited (severe persistent) 3
• Lung function: FEV₁ ≥80% predicted with normal FEV₁/FVC (intermittent/mild), FEV₁ 60-80% predicted (moderate), or FEV₁ <60% predicted (severe persistent) 3, 2

Risk Domain Assessment

• Exacerbations requiring oral corticosteroids: 0-1/year suggests lower severity; ≥2/year indicates higher severity regardless of other features 3

Critical principle: Assign severity to the most severe category in which any single feature occurs 3

Initial Treatment Selection by Severity

Intermittent Asthma

• Preferred: As-needed low-dose ICS-formoterol (replaces outdated SABA-only approach) 1
• This reduces exacerbations compared to SABA monotherapy 1

Mild Persistent Asthma (Step 2)

• Preferred: Daily low-dose inhaled corticosteroid (ICS) as first-line controller therapy 3, 1, 2
• Alternative: As-needed low-dose ICS-formoterol 1
• ICS improves control more effectively than any other single long-term controller medication 1, 2
• Add SABA for quick relief of breakthrough symptoms 1

Moderate Persistent Asthma (Step 3-4)

• Preferred Step 3: Low-to-medium dose ICS plus long-acting beta-agonist (LABA) 3, 1
• Preferred Step 4: Medium-dose ICS-LABA combination 3
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist, theophylline (requires serum monitoring), or zileuton (requires liver function monitoring) 3
• ICS-LABA demonstrates synergistic effects achieving efficacy equivalent to or better than doubling ICS dose alone 1

Severe Persistent Asthma (Step 5-6)

• Preferred Step 5: High-dose ICS-LABA combination, plus consider omalizumab for patients with documented allergies 3, 2
• Preferred Step 6: High-dose ICS-LABA plus oral corticosteroid, plus consider omalizumab for allergic patients 3
• Consider adding long-acting muscarinic antagonist (triple therapy) to improve symptoms, lung function, and reduce exacerbations 1
• Specialist consultation recommended at Step 4 or higher 3, 4

Ongoing Assessment of Asthma Control (Drives All Treatment Adjustments)

Assess control at every clinical encounter using these criteria 3, 2:

Well-Controlled Asthma

• Symptoms ≤2 days/week 3
• Rescue bronchodilator use ≤2 days/week 3
• No nocturnal or early morning awakening 3
• No limitations on work, school, or exercise 3
• PEF or FEV₁ ≥80% predicted or personal best 3

Not Well-Controlled or Very Poorly Controlled

• Any deviation from well-controlled criteria indicates need for treatment adjustment 3, 2
• Use validated tools: Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) 3, 1, 2
• PEF <60% predicted or personal best indicates very poor control 3

Treatment Adjustment Algorithm

Stepping Up Therapy

• Step up immediately if control is inadequate 3, 1
• Before stepping up, verify medication adherence, inhaler technique, environmental trigger control, and comorbid conditions 3, 1
• Increasing SABA use (>2 days/week or >2 nights/month) indicates inadequate control requiring intensified anti-inflammatory therapy 1

Stepping Down Therapy

• Step down only after asthma is well-controlled for at least 3 months 3, 2
• Reduce treatment to the lowest step that maintains control 3, 1

Follow-Up Visit Frequency

• Every 2-6 weeks when initiating therapy or stepping up treatment 2, 4
• Every 1-6 months once control is achieved 2, 4
• Every 3 months if considering step-down therapy 2

Essential Non-Pharmacological Management

Patient Education Components

• Provide written asthma action plan to all patients with instructions for daily management, recognizing worsening symptoms, medication adjustments, and when to seek emergency care 1, 2
• Teach and verify proper inhaler technique at every visit—inadequate technique is a common cause of poor control 1, 2
• Educate on difference between daily controller medications and as-needed quick-relief medications 1

Environmental Control

• Perform allergy testing (skin or specific IgE) for perennial indoor allergens in all patients with persistent asthma requiring daily medications 1, 2
• Identify and reduce exposure to house dust mite, cockroach, cat/dog allergens, mold, and tobacco smoke in sensitized patients 1, 2
• Eliminate tobacco smoke exposure completely 1

Comorbidity Management

• Treat allergic rhinitis and chronic rhinosinusitis 1, 2
• Manage gastroesophageal reflux disease (GERD) 1, 2
• Address obesity, anxiety, and depression 1, 2
• Provide annual influenza vaccination for all patients with persistent asthma 1

Self-Monitoring

• Instruct patients to monitor control through either symptom monitoring or peak flow monitoring—both have similar benefits 3, 1
• Peak flow monitoring particularly important for patients with moderate-severe asthma, history of severe exacerbations, or poor symptom perception 2
• Teach patients to recognize when PEF drops below 75% of personal best or predicted value, indicating need to increase treatment 1

Critical Pitfalls to Avoid

• Never use LABA as monotherapy—increases risk of serious asthma-related events 2
• Doubling ICS doses during exacerbations is not effective—use oral corticosteroids instead 2
• Do not prescribe antibiotics unless bacterial infection is confirmed—they are overused without evidence of benefit 1
• Never use sedation during acute exacerbations—it is contraindicated and dangerous 1
• Asthma severity is not static—control status changes over time, requiring continual reassessment 3, 5
• Point-in-time assessments may underestimate disease severity and contribute to inadequate therapy 6