What is the current recommended therapy for mild (simple) asthma?

Latest Treatment of Simple (Mild) Asthma

For adults and adolescents ≥12 years with mild persistent asthma, start with daily low-dose inhaled corticosteroids (ICS) plus as-needed short-acting beta-agonist (SABA), or alternatively, use as-needed ICS plus SABA taken together during symptom worsening. 1

First-Line Treatment Strategy

Daily Low-Dose ICS (Preferred for Most Patients)

• Initiate low-dose ICS at fluticasone propionate 100–250 μg/day or budesonide 200–400 μg/day, administered twice daily, with as-needed SABA for quick relief. 2
• ICS monotherapy is the most effective single long-term controller medication, demonstrating superior outcomes compared to leukotriene modifiers, theophylline, or cromones in improving symptom scores, lung function, and reducing exacerbations. 2
• Use a spacer or valved holding chamber with metered-dose inhalers to increase lung deposition and reduce oropharyngeal side effects like thrush. 2
• Instruct patients to rinse their mouth and spit after each inhalation to minimize local adverse effects. 2

As-Needed ICS + SABA (Alternative for Adherence Concerns)

• For patients ≥12 years who may struggle with daily medication adherence, as-needed ICS plus SABA used concomitantly (one after the other) during symptom worsening is an acceptable alternative. 1
• This approach provides non-inferior control of exacerbations while reducing total ICS exposure, though it may be less effective for day-to-day symptom control compared with daily low-dose ICS. 2
• The practical regimen is 2–4 puffs of albuterol followed by 80–250 μg of beclomethasone equivalent every 4 hours as needed for asthma symptoms. 1
• Currently, these medications must be administered sequentially in two separate inhalers in the United States, as no fixed-dose combined ICS/SABA inhaler is commercially available. 2

Important Caveats for As-Needed ICS Approach

• Patients with low or high perception of symptoms are not good candidates for as-needed ICS therapy. 1
• Those with low symptom perception risk ICS undertreatment, while those with high symptom perception risk overtreatment. 1
• Regular low-dose ICS with SABA for quick-relief therapy may be preferred for such patients. 1
• This recommendation does not apply to children aged 5–11 years because this therapy has not been adequately studied in this age group. 1

Alternative Controller Options (Less Preferred)

• Leukotriene receptor antagonists (e.g., montelukast, zafirlukast) are viable alternatives but are not preferred for mild persistent asthma. 2
• Cromolyn sodium, nedocromil, and sustained-release theophylline can be used as alternatives when ICS are not appropriate, but these are less effective than ICS. 2

Indicators for Treatment Intensification

Red Flags Requiring Step-Up Therapy

• SABA use >2 days per week for symptom relief (excluding use for exercise-induced bronchospasm) signals inadequate control and the need to step up therapy. 1, 2
• Nighttime awakenings >2 nights per month due to asthma. 2
• Using more than one SABA canister per month. 2

Preferred Step-Up Strategy

• If asthma remains uncontrolled after 2–6 weeks on low-dose ICS, add a long-acting beta-agonist (LABA) to low-dose ICS rather than increasing ICS dose alone. 2
• This provides greater improvement in lung function, symptoms, and exacerbation reduction compared to increasing ICS dose. 2
• LABAs must NEVER be used as monotherapy for asthma because this increases the risk of severe exacerbations and asthma-related mortality. 2, 3

Monitoring and Follow-Up

• Assess treatment response at 2–6 week intervals when initiating or stepping up therapy. 2
• Perform spirometry at initial assessment, after treatment stabilization, and at least every 1–2 years. 2
• Verify proper inhaler technique before escalating therapy, as poor technique is a common cause of apparent treatment failure. 2

Step-Down Strategy

• Once asthma control is sustained for 2–4 months, step down therapy to the minimum dose required to maintain control. 2
• Continue monitoring for at least 3 months of stable control before considering further dose reduction. 2

Common Pitfalls to Avoid

• Delaying ICS initiation in persistent asthma can worsen long-term outcomes; early intervention improves long-term outcomes. 2
• Using regular chronic SABA as a long-term management strategy can mask poorly controlled persistent asthma and delay appropriate treatment escalation. 2, 4, 5
• Over-reliance on SABA bronchodilators for rapid symptom relief is common in real life and potentially leads to an increased risk of asthma morbidity and mortality. 6
• Smokers have decreased responsiveness to steroids due to persistent airway irritation. 2

Special Considerations for Children

Ages 0–4 Years with Recurrent Wheezing

• In children aged 0–4 years with recurrent wheezing triggered by respiratory tract infections and no wheezing between infections, start a short course of daily ICS at the onset of a respiratory tract infection with as-needed SABA for quick-relief therapy. 1

Ages 5–11 Years

• The as-needed ICS + SABA approach has not been adequately studied in children aged 5–11 years, so daily low-dose ICS remains the standard recommendation. 1