What is the recommended first‑line treatment regimen for an adult with bronchial asthma?

First-Line Treatment for Bronchial Asthma in Adults

For adults with newly diagnosed bronchial asthma, initiate low-dose inhaled corticosteroids (ICS) as the cornerstone of therapy—specifically fluticasone propionate 100–250 mcg/day or budesonide 200–400 mcg/day administered twice daily via metered-dose inhaler—combined with as-needed short-acting beta-agonist (SABA) for acute symptom relief. 1

Why ICS Monotherapy Is the Foundation

• Low-dose ICS is the single most effective long-term controller medication for persistent asthma, demonstrating superior outcomes compared to leukotriene modifiers, theophylline, or cromones in reducing symptoms, exacerbations, and need for rescue bronchodilators. 2, 1
• ICS therapy reduces the frequency of oral corticosteroid courses and hospitalizations while improving symptom scores. 1
• There are no clinically meaningful differences among various ICS types (fluticasone, budesonide, beclomethasone, mometasone) when used at equivalent doses, so selection can be based on availability and cost. 1

Optimizing Delivery and Technique

• Use a spacer or valved holding chamber with metered-dose inhalers to increase lung deposition, reduce oropharyngeal side effects (thrush, hoarseness), and improve efficacy. 1
• Instruct patients to rinse mouth and spit after each inhalation to further minimize local adverse effects. 1
• Verify correct inhaler technique at every visit—improper technique is a common cause of apparent treatment failure and must be corrected before escalating therapy. 1, 3

When to Step Up Therapy

• If asthma remains uncontrolled after 2–6 weeks on low-dose ICS (defined as SABA use >2–3 times daily for symptom relief, nighttime awakenings, or persistent daytime symptoms despite optimal inhaler technique and adherence), add a long-acting beta-agonist (LABA) to the existing low-dose ICS rather than increasing ICS dose alone. 1
• The preferred step-up regimen for moderate persistent asthma is combination ICS/LABA therapy (e.g., fluticasone/salmeterol 250/50 mcg twice daily or budesonide/formoterol 200/6 mcg twice daily), which provides greater improvement in lung function, symptoms, and exacerbation reduction compared to doubling ICS dose. 2, 1
• LABAs must never be used as monotherapy—this increases the risk of severe exacerbations and asthma-related deaths; LABAs must always be combined with ICS in a single inhaler or as separate inhalers. 2, 1

Alternative Controller Options (When ICS Is Not Tolerated)

• Leukotriene receptor antagonists (montelukast 10 mg once daily for adults, zafirlukast 20 mg twice daily for patients ≥12 years) are appropriate alternative therapies for mild persistent asthma, though they are less effective than ICS. 2, 1
• Cromolyn sodium and nedocromil are alternative but not preferred medications for mild persistent asthma (step 2 care). 2
• Sustained-release theophylline is a mild-to-moderate bronchodilator used as alternative, not preferred, therapy for mild persistent asthma; serum theophylline concentration monitoring is essential due to narrow therapeutic index and drug interactions. 2

Rescue Medication Strategy

• Short-acting beta-agonists (albuterol, levalbuterol) are the treatment of choice for acute symptom relief and should be available to all patients. 2
• Increasing SABA use or using SABA >2 days per week for symptom relief (not prevention of exercise-induced bronchoconstriction) indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy. 2, 1
• Regularly scheduled, daily, chronic use of SABA is not recommended—this approach does not address underlying inflammation and may mask poorly controlled persistent asthma. 2

Monitoring Parameters and Follow-Up

• Assess treatment response within 2–6 weeks of initiating therapy, evaluating symptom frequency, nighttime awakenings, SABA use, activity limitations, and lung function (spirometry or peak expiratory flow). 1
• Once asthma control is sustained for 2–4 months, step down therapy to the minimum dose required to maintain control, and continue monitoring for at least 3 months of stable control before considering further dose reduction. 1
• Check medication adherence and environmental trigger exposure (smoking, allergens, occupational exposures) before any treatment escalation. 2, 3

Common Pitfalls to Avoid

• Do not start with high-dose ICS—starting with high-dose ICS provides no clinically meaningful advantage over starting with low-dose ICS, with only a 5% improvement in FEV1 according to Cochrane systematic review. 1
• Do not use LABA monotherapy—this critical error increases mortality risk and severe exacerbations. 2, 1
• Do not rely solely on SABA for persistent symptoms—this approach fails to address underlying inflammation and allows disease progression. 2, 1
• Smokers have decreased responsiveness to corticosteroids due to persistent irritation and scarring; smoking cessation counseling is essential. 1

Special Considerations for Local Side Effects

• Common local effects of ICS include oral candidiasis, hoarseness, and dysphonia. 1
• Adding a spacer device, switching from dry-powder inhaler to metered-dose inhaler with spacer, or changing the delivery system can manage these local effects. 1
• For doses >800 mcg/day beclomethasone equivalent, use large-volume spacer devices to reduce local and systemic adverse effects. 3