What is the stepwise treatment plan for asthma?

Stepwise Treatment of Asthma

Asthma management follows a 6-step approach where treatment intensity escalates based on symptom frequency and severity, with inhaled corticosteroids (ICS) forming the cornerstone of therapy for all persistent asthma, and short-acting beta-agonists (SABA) reserved strictly for as-needed symptom relief at all steps. 1

Core Principles

The stepwise approach is designed to gain and maintain control in both the impairment domain (symptoms, activity limitation) and risk domain (exacerbations, lung function decline). 1 Therapy should be stepped up when control is inadequate and stepped down after at least 3 months of well-controlled asthma to identify the minimum effective medication regimen. 1

Before stepping up therapy, always verify: inhaler technique, medication adherence, environmental trigger exposure, and comorbid conditions (allergic rhinitis, sinusitis, GERD). 2, 1 These factors commonly masquerade as poor asthma control and are particularly problematic in elderly patients. 2

The Six Steps

Step 1: Intermittent Asthma

• Symptoms <2 days/week, nighttime awakenings <2x/month, FEV1 >80% predicted 1
• Treatment: SABA as needed only; no daily controller medication required 1
• Quick-relief: Short-acting inhaled beta-agonist as needed 1

Step 2: Mild Persistent Asthma

• Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month 1
• Preferred treatment: Low-dose ICS 1
• Alternative options: Leukotriene modifiers, cromolyn, nedocromil, or sustained-release theophylline (5-15 mcg/mL serum concentration) 1
• Quick-relief: SABA as needed 1

Critical caveat: Inhaled corticosteroids are the most effective anti-inflammatory medication available and superior to cromolyn, nedocromil, and other alternatives for preventing exacerbations. 1

Step 3: Moderate Persistent Asthma

• Daily symptoms, nighttime awakenings >1x/week but not nightly, FEV1 60-80% predicted 1
• Preferred treatment: Low-to-medium dose ICS PLUS long-acting beta-agonist (LABA) 1, 2
• Alternative for children <5 years: Medium-dose ICS alone 1
• Other alternatives: Low-to-medium dose ICS plus leukotriene modifier OR low-to-medium dose ICS plus theophylline 1
• Quick-relief: SABA as needed; oral corticosteroids may be required for exacerbations 1
• Consider pulmonology consultation at this step 1

LABA safety warning: LABAs carry an FDA Black Box warning and must NEVER be used as monotherapy. 1 Patients must continue ICS therapy even when symptoms improve significantly on LABA. 1 Daily LABA use should not exceed 100 mcg salmeterol or 24 mcg formoterol. 1 LABAs are not indicated for acute symptoms or exacerbations. 1

Step 4: Severe Persistent Asthma

• Symptoms throughout the day, nighttime awakenings often ≥7x/week, FEV1 <60% predicted 1
• Preferred treatment: Medium-to-high dose ICS PLUS LABA 2
• If needed, add: Oral corticosteroids 1
• Consider: Monoclonal anti-IgE therapy 1
• Quick-relief: SABA as needed; oral corticosteroids frequently required 1
• Specialist consultation strongly recommended 2

Steps 5-6: Highest Severity

• Treatment: High-dose ICS and LABA plus systemic corticosteroids if needed 1
• Additional options: Anti-IgE therapy, consideration of other biologics 1

Adjunctive Therapies Across Steps

Allergen Immunotherapy

Consider subcutaneous allergen immunotherapy for patients with persistent allergic asthma at Steps 2-4. 1 The role of allergy is greater in children than adults. 1 Clinicians administering immunotherapy must be prepared to treat anaphylaxis. 1

Monitoring SABA Use

If a patient uses more than one SABA canister per month, this signals inadequate control and necessitates stepping up daily controller therapy. 1 Frequent SABA use indicates the need to initiate or intensify daily long-term control therapy. 1

With viral respiratory symptoms, SABA every 4-6 hours up to 24 hours is acceptable (longer with physician consultation). 1 Consider a short course of oral systemic corticosteroids if exacerbation is severe or the patient has a history of severe exacerbations. 1

Comorbidity Management at Every Step

Evaluate and treat comorbid conditions when symptoms persist despite medication adjustments: allergic rhinitis, sinusitis, gastroesophageal reflux, and medication sensitivities. 1 All patients with persistent asthma require annual influenza vaccination to prevent respiratory infections that trigger exacerbations. 1

Allergy testing for perennial indoor allergens is recommended for patients with persistent asthma taking daily medications, followed by avoidance strategies. 1

Patient Education and Written Action Plans

At every step, develop a written asthma management plan in consultation with the patient or caregiver. 1 The plan should clarify treatment expectations, provide easy reference for self-management, and be reviewed at every follow-up visit. 1 For children, provide copies to all caregivers and the school. 1

Reassessment and Step-Down

Assess control regularly using validated tools (Asthma Control Test, Asthma Control Questionnaire, Asthma Therapy Assessment Questionnaire) and objective measures (FEV1, peak flow). 2 Reassess 2-6 weeks after any therapy change. 2

Step down therapy if asthma is well-controlled for at least 3 months to identify the minimum effective dose and reduce medication burden, particularly corticosteroid-related adverse effects (bone loss, cataracts, glaucoma, adrenal suppression). 2 This is especially important in elderly patients. 2