What is the stepwise treatment approach for asthma according to the latest guidelines?

Stepwise Treatment of Asthma According to Latest Guidelines

For adults and adolescents with asthma, the preferred approach is Track 1 using low-dose ICS-formoterol as both maintenance and reliever therapy across all severity levels, starting with as-needed use in mild asthma and progressing to daily maintenance plus as-needed use in moderate-to-severe disease. 1, 2, 3

Initial Treatment Selection Based on Severity

Step 1: Intermittent Asthma

• Preferred: As-needed low-dose ICS-formoterol (not SABA alone) for patients with symptoms <2 times/month, no nocturnal awakenings, and FEV₁ >80% predicted 1, 2
• Alternative (Track 2): As-needed SABA only, though this is no longer the preferred first-line approach due to increased exacerbation risk 2, 3

Step 2: Mild Persistent Asthma

• Preferred (Track 1): As-needed low-dose ICS-formoterol for both symptom relief and anti-inflammatory effect 1, 4, 2
• Alternative (Track 2): Daily low-dose ICS (fluticasone 100-250 mcg/day or equivalent) plus as-needed SABA 5, 1, 6
• Other alternatives: Leukotriene receptor antagonist, cromolyn, nedocromil, or theophylline (requires serum monitoring) 5, 6

Step 3: Moderate Persistent Asthma

• Preferred (Track 1): Low-dose ICS-formoterol daily maintenance plus as-needed for symptoms (MART approach) 1, 4, 2
• Alternative (Track 2): Low-dose ICS plus LABA (separate inhalers) with as-needed SABA, OR medium-dose ICS alone 5, 6
• Other alternatives: Low-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 5

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred (Track 1): Medium-dose ICS-formoterol as maintenance and reliever therapy 4, 2
• Alternative (Track 2): Medium-dose ICS plus LABA with as-needed SABA 5, 6
• Other alternatives: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 5

Step 5: Severe Persistent Asthma

• Preferred (Track 1): High-dose ICS-formoterol as maintenance and reliever therapy, plus add-on long-acting muscarinic antagonist (LAMA) 1, 4, 2
• Consider omalizumab for patients with documented allergic sensitization 5, 6
• Alternative (Track 2): High-dose ICS plus LABA with as-needed SABA, plus LAMA 5

Step 6: Refractory Severe Asthma

• High-dose ICS plus LABA plus oral corticosteroids 5, 6
• Consider omalizumab for allergic asthma 5
• Before initiating oral corticosteroids, trial high-dose ICS plus LABA plus leukotriene receptor antagonist, theophylline, or zileuton 5
• Bronchial thermoplasty is not recommended as standard care and should only be used within research protocols 4

Adjusting Therapy Based on Control Assessment

Well-Controlled Asthma

• Maintain current step 5, 6
• Schedule follow-up every 1-6 months 5, 1, 6
• Consider stepping down after ≥3 months of sustained control 5, 6

Not Well-Controlled Asthma

• Before stepping up: Verify medication adherence, inhaler technique, environmental trigger control, and management of comorbidities (GERD, rhinosinusitis, obesity, obstructive sleep apnea) 5, 6
• If technique and adherence are satisfactory, step up one step 5, 6
• Discontinue any alternative therapy before stepping up to preferred therapy 5, 6
• Reassess in 2-6 weeks 5, 6

Very Poorly Controlled Asthma

• Consider short course of oral systemic corticosteroids (prednisolone 30-40 mg daily for 7-21 days, no taper needed for courses ≤2 weeks) 5, 6
• Step up 1-2 steps 5
• Reassess in 2 weeks 5

Control Assessment Criteria (Adults ≥12 Years)

Well-Controlled: ≤2 days/week symptoms, ≤2 nighttime awakenings/month, ≤2 days/week SABA use, no activity limitation, FEV₁ >80% predicted, 0-1 oral corticosteroid courses/year, ACT ≥20 5, 6

Not Well-Controlled: >2 days/week symptoms, 1-3 nighttime awakenings/week, >2 days/week SABA use, some activity limitation, FEV₁ 60-80% predicted, ≥2 oral corticosteroid courses/year, ACT 16-19 5, 6

Very Poorly Controlled: Daily symptoms, ≥4 nighttime awakenings/week, SABA several times/day, extremely limited activity, FEV₁ <60% predicted, ACT ≤15 5, 6

Essential Adjunctive Measures at Every Step

Inhaler Technique and Device Selection

• Always use a spacer with metered-dose inhalers (MDIs) to enhance drug distribution and effectiveness 5, 6
• Verify proper inhaler technique at every visit before any treatment escalation 1, 6
• Poor technique is a common cause of apparent treatment failure 6

Environmental Control

• Identify specific allergen sensitivities through skin or in vitro testing in patients with persistent asthma 5, 6
• Implement multifaceted, allergen-specific mitigation strategies (single interventions are generally ineffective) 5, 4
• Advise all patients to avoid tobacco smoke exposure 5, 6
• Avoid NSAIDs in aspirin-sensitive asthma and all β-blockers (even β₁-selective agents) 6

Immunotherapy

• Consider subcutaneous allergen immunotherapy as adjunct therapy when clear relationship exists between symptoms and specific allergen exposure 5, 4
• Evidence is strongest for single-allergen immunotherapy (house dust mite, animal danders, pollens) 5
• Sublingual immunotherapy is not recommended specifically for asthma 4

Monitoring Tools

• Use validated questionnaires (ACT, ACQ, or ATAQ) at every visit for rapid impairment assessment 5, 6
• Perform spirometry at initial assessment, after treatment initiation, during loss of control, and at least every 1-2 years 1, 6
• Fractional exhaled nitric oxide (FeNO) testing can assist in diagnosis and monitoring but should not be used alone to diagnose or monitor asthma 4

Vaccination

• Administer annual influenza vaccination to all asthma patients due to higher risk of influenza-related complications 6
• Note: Influenza vaccination does not reduce asthma exacerbation frequency 6

Specialist Referral Indications

Refer to an asthma specialist when: 5, 6

• Difficulty achieving or maintaining control
• ≥2 oral corticosteroid courses in one year
• Hospitalization for exacerbation
• Need for Step 4 or higher care
• Consideration of immunotherapy, omalizumab, or other biologic therapy
• Additional diagnostic testing is indicated

Critical Pitfalls to Avoid

• Never prescribe LABA without concurrent ICS due to increased risk of asthma-related death 1, 6
• Never treat asthma with SABA alone in patients not using regular ICS due to increased exacerbation risk 2, 3
• Do not increase therapy without first confirming adherence, inhaler technique, environmental control, and comorbidity management 5, 6
• Do not underdose systemic corticosteroids during exacerbations, as underuse is a documented cause of preventable asthma deaths 1
• Do not prescribe antibiotics for viral-induced exacerbations unless bacterial infection is clearly documented 1
• Do not accept ongoing symptoms or frequent SABA use as "normal" for asthma patients 6
• Recognize that patients with intermittent asthma can still experience severe, life-threatening exacerbations 6

Written Asthma Action Plan

Every patient must receive a written asthma action plan containing: 1, 3

• Symptom/peak flow monitoring parameters
• Predetermined action triggers for treatment escalation
• Written guidance distinguishing "reliever" (SABA or ICS-formoterol) from "preventer" (daily ICS) medications
• Recognition that nocturnal symptoms are a critical warning sign requiring immediate treatment escalation 1