What is the appropriate stepwise management for a patient with persistent asthma, including controller and rescue therapy, dosing, and follow‑up?

Stepwise Management of Persistent Asthma

All patients with persistent asthma require daily inhaled corticosteroid (ICS) therapy as the cornerstone of long-term control, combined with a short-acting β₂-agonist (SABA) for rescue therapy. 1, 2

Initial Classification and Treatment Selection

Severity Assessment Before Treatment

Classify severity using both impairment and risk domains—assign the patient to the most severe category present in either domain 2:

Impairment criteria (assess past 2-4 weeks):

• Daytime symptoms: ≤2 days/week = intermittent; >2 days/week but not daily = mild persistent; daily = moderate persistent; throughout the day = severe persistent 2
• Nighttime awakenings: ≤2/month = intermittent; 3-4/month = mild persistent; >1/week but not nightly = moderate persistent; ≥7/week = severe persistent 2
• SABA use for symptoms: ≤2 days/week = intermittent; >2 days/week but not daily = mild persistent; daily = moderate persistent; several times/day = severe persistent 1, 2
• Activity limitation: None = intermittent; minor = mild persistent; some = moderate persistent; extreme = severe persistent 2
• Lung function (FEV₁): >80% predicted = intermittent/mild; 60-80% = moderate; <60% = severe persistent 2

Risk criteria: ≥2 exacerbations requiring oral corticosteroids in the past year automatically upgrades to higher severity regardless of impairment 2

Step-Based Initial Therapy

Severity	Step	Preferred Controller	Rescue Therapy	Dosing
Mild Persistent	2	Low-dose ICS daily	SABA as needed	Budesonide 180-400 µg/day or fluticasone 88-264 µg/day [2,3]
Moderate Persistent	3	Low-to-medium dose ICS + LABA combination	SABA as needed	Fluticasone-salmeterol 100-250/50 µg twice daily or budesonide-formoterol 80-160/4.5 µg twice daily [1,2,3]
Severe Persistent	4-5	Medium-to-high dose ICS + LABA	SABA as needed	Fluticasone-salmeterol 250-500/50 µg twice daily; consider adding omalizumab if allergic asthma documented [1,2]
Refractory Severe	6	High-dose ICS + LABA + oral corticosteroid	SABA as needed	Add prednisone 5-10 mg daily (lowest effective dose) [1,3]

Critical principle: ICS is the most effective long-term control medication across all severity levels—more effective than any other single controller 1, 2, 4

Alternative controllers (when ICS not tolerated): Leukotriene receptor antagonists (montelukast 10 mg daily), cromolyn, or theophylline (requires serum monitoring), though all are less effective than ICS 1, 3, 5

Never prescribe LABA as monotherapy—it must always be combined with ICS to avoid increased mortality risk 2, 3

Ongoing Assessment of Asthma Control

At every visit, assess control using these criteria 1, 2:

Well-controlled (all must be present):

• Daytime symptoms ≤2 days/week 2, 3
• No nighttime awakenings 2, 3
• SABA use ≤2 days/week 1, 2
• No activity limitation 2, 3
• FEV₁ or peak flow ≥80% predicted or personal best 2, 3
• 0-1 exacerbations requiring oral corticosteroids per year 2
• Asthma Control Test (ACT) score ≥20 2, 3

Not well-controlled (any present):

• Symptoms >2 days/week 2, 3
• 1-3 nighttime awakenings/week 2, 3
• SABA use >2 days/week 2, 3
• Some activity limitation 2, 3
• FEV₁ or peak flow 60-80% predicted 2, 3
• ≥2 exacerbations requiring oral corticosteroids per year 2
• ACT score 16-19 2, 3

Very poorly controlled:

• Symptoms throughout the day 2, 3
• ≥4 nighttime awakenings/week 2, 3
• SABA several times/day 2, 3
• Extreme activity limitation 2, 3
• FEV₁ or peak flow <60% predicted 2, 3
• ACT score ≤15 2, 3

Use validated questionnaires (ACT, Asthma Control Questionnaire, or ATAQ) at each visit for rapid assessment 2, 3

Treatment Adjustment Algorithm

When Well-Controlled

• Maintain current step and schedule follow-up every 1-6 months 3
• Consider stepping down after ≥3 months of sustained control to identify the minimum medication needed 1, 3
• Reduce ICS dose by 25-50% every 3 months while monitoring closely 3

When Not Well-Controlled

Before stepping up therapy, verify 1, 3:

1. Medication adherence—directly ask about missed doses 1
2. Inhaler technique—demonstrate and have patient return demonstration 1, 3
3. Environmental trigger control—identify and mitigate allergen/irritant exposures 1, 2
4. Comorbidity management—treat GERD, rhinitis, obesity, obstructive sleep apnea 1, 2, 6

If adherence and technique are adequate:

• Step up one level 3
• Discontinue any alternative therapy before stepping up 3
• Reassess in 2-6 weeks 3

When Very Poorly Controlled

• Prescribe oral prednisone 30-40 mg daily for 7-21 days (no taper needed for courses ≤2 weeks) 1, 3
• Step up 1-2 levels 3
• Reassess in 2 weeks 3

Essential Non-Pharmacologic Components

Inhaler Technique and Device Selection

• Start with metered-dose inhaler (MDI) + spacer for all patients—spacers improve drug delivery and are more effective than MDI alone 3
• Verify technique at every visit before any step-up—poor technique is a common cause of apparent treatment failure 1, 2, 3
• If MDI + spacer too bulky, switch to dry-powder inhaler the patient can operate correctly 3

Written Asthma Action Plan

Provide to all patients, especially those with moderate-severe persistent asthma, history of severe exacerbations, or poorly controlled disease 1, 2:

• Daily controller medication regimen 1
• When to increase treatment (symptoms worsen, peak flow <80% personal best) 2
• When to start oral corticosteroids (peak flow <60% personal best, symptoms not responding to SABA) 1, 3
• When to seek emergency care (severe breathlessness, peak flow <50% after treatment) 1

Environmental Control and Trigger Avoidance

• Perform allergy testing (skin or specific IgE) in all patients with persistent asthma requiring daily medication 1, 2
• Implement comprehensive allergen reduction for identified sensitivities—single interventions are ineffective 1, 2
• Eliminate tobacco smoke exposure completely—counsel cessation at every visit 1, 2, 3
• Avoid NSAIDs in aspirin-sensitive asthma and all β-blockers (even β₁-selective) 3

Patient Education

Teach at every visit 1:

• Difference between controller medications (prevent symptoms, taken daily) and rescue medications (relieve symptoms, used as needed) 1
• How to recognize worsening asthma (increased symptoms, nighttime awakenings, increased SABA use) 1
• Self-monitoring using symptoms or peak flow—both approaches provide comparable benefits 2

Follow-Up Schedule

• Initial visit after starting therapy: 2-4 weeks to assess response, lung function, and inhaler technique 2
• Well-controlled asthma: Every 1-6 months 3
• After stepping up therapy: 2-6 weeks 3
• After stepping down therapy: 3 months 3

At each visit, assess 1, 2:

• Symptom frequency (day and night) over past 2-4 weeks 2
• SABA use (average puffs per day) 1
• Activity limitation 2
• Exacerbations or unscheduled visits since last appointment 1
• Lung function (FEV₁ or peak flow) 2, 3
• Medication adherence and problems 1
• Inhaler technique 1, 3

Specialist Referral Criteria

Refer to pulmonology/allergy specialist when 1, 2, 3:

• Difficulty achieving or maintaining control despite optimized therapy 1, 2
• Step 4 or higher care required (medium-to-high dose ICS-LABA) 1, 2
• ≥2 oral corticosteroid courses in one year 3
• Hospitalization for asthma exacerbation 3
• Consideration of omalizumab, allergen immunotherapy, or additional testing 1, 2

Common Pitfalls to Avoid

• Do not increase therapy without first confirming adherence, proper inhaler technique, environmental control, and comorbidity management 1, 2, 3
• Do not accept ongoing symptoms or frequent SABA use (>2 days/week) as normal—this indicates need for controller therapy or step-up 1, 2
• Never use LABA without concurrent ICS—monotherapy increases mortality 2, 3
• Do not rely on peak flow meters for diagnosis—they are for monitoring only; spirometry is required for diagnosis 2
• Do not assume influenza vaccination reduces asthma exacerbations—it prevents influenza complications but does not improve asthma control 3