Stepwise Algorithm to Treat Asthma
Initiate treatment based on initial severity classification using both impairment and risk domains, then adjust therapy at every visit according to control status—stepping up when control is inadequate and stepping down after ≥3 months of sustained control.
Initial Severity Classification (Before Starting Therapy)
Classify severity using both impairment and risk domains; assign the patient to the most severe category present in any single feature 1.
Impairment Domain (Past 2–4 Weeks)
| Severity | Daytime Symptoms | Night Awakenings | SABA Use | Activity Limitation | FEV₁ (% predicted) |
|---|---|---|---|---|---|
| Intermittent | ≤2 days/week | ≤2×/month | ≤2 days/week | None | >80% |
| Mild Persistent | >2 days/week but not daily | 3–4×/month | >2 days/week but not daily | Minor | >80% |
| Moderate Persistent | Daily | >1×/week but not nightly | Daily | Some | 60–80% |
| Severe Persistent | Throughout day | ≥4×/week (often 7×/week) | Several times/day | Extreme | <60% |
Table derived from NAEPP EPR-3 guidelines 1.
Risk Domain
- ≥2 exacerbations requiring oral systemic corticosteroids in the past year automatically upgrades the patient to persistent asthma (and higher severity) regardless of impairment measures 1.
Stepwise Pharmacologic Treatment Algorithm
Step 1: Intermittent Asthma
- Preferred: As-needed low-dose ICS-formoterol (replaces outdated SABA-only approach) 2.
- Alternative: As-needed SABA alone (less effective for preventing exacerbations) 1.
Step 2: Mild Persistent Asthma
- Preferred: Daily low-dose inhaled corticosteroid (ICS) + as-needed SABA 1, 2.
- Alternative (if ICS not tolerated): Leukotriene receptor antagonist, cromolyn, or theophylline (all less effective than ICS) 2.
Step 3: Moderate Persistent Asthma
- Preferred: Low-to-medium dose ICS + LABA combination inhaler 1, 2.
- Alternative: Medium-dose ICS alone, or low-dose ICS + leukotriene receptor antagonist 1, 2.
- Consider specialist consultation at Step 3 1.
Step 4: Moderate-to-Severe Persistent Asthma
- Preferred: Medium-dose ICS-LABA combination 1, 2.
- Refer to pulmonology/allergy specialist at this step 1, 2.
Step 5: Severe Persistent Asthma
- Preferred: High-dose ICS-LABA + consider adding omalizumab (anti-IgE biologic) if allergic asthma is documented by positive skin testing or specific IgE to perennial allergens 1, 2.
- Alternative add-ons: Long-acting muscarinic antagonist (LAMA) for triple therapy 2.
Step 6: Refractory Severe Persistent Asthma
- Preferred: High-dose ICS-LABA + maintenance oral corticosteroid (lowest effective dose, e.g., prednisone 5–10 mg daily) 1, 2.
- Consider omalizumab or other biologics if allergic phenotype 1, 2.
Ongoing Assessment of Asthma Control (At Every Visit)
Control assessment drives all treatment adjustments after initial therapy is started 1, 2.
Well-Controlled Asthma Criteria (All Must Be Met)
- Daytime symptoms ≤2 days/week 1, 2.
- No nighttime awakenings 1, 2.
- SABA rescue use ≤2 days/week 1, 2.
- No limitation of work, school, or exercise 1, 2.
- FEV₁ or peak expiratory flow ≥80% predicted or personal best 1, 2.
- No exacerbations requiring oral corticosteroids 2.
Use validated tools such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) to quantify control; ACT score ≥20 indicates well-controlled asthma 2.
Treatment Adjustment Algorithm
Before Stepping Up Therapy
Always verify the following before increasing medication 1, 2:
- Medication adherence – directly ask about missed doses 2.
- Inhaler technique – demonstrate and have patient return demonstration; poor technique is a common cause of treatment failure 2.
- Environmental trigger control – identify and mitigate allergen/irritant exposures (tobacco smoke, dust mite, cockroach, pet dander, mold) 2.
- Comorbidity management – treat GERD, allergic rhinitis, obesity, obstructive sleep apnea, anxiety/depression 2.
When to Step Up
- Any deviation from well-controlled criteria warrants stepping up by one step 1, 2.
- Reassess in 2–4 weeks after adjustment 2.
- For very poorly controlled asthma (symptoms throughout day, PEF <60% predicted), consider stepping up 1–2 steps and adding a short course of oral prednisone 30–40 mg daily for 7–21 days 2, 3.
When to Step Down
- Consider step-down only after ≥3 months of sustained well-controlled asthma 1, 2.
- Reduce ICS dose by 25–50% every 3 months while monitoring closely for loss of control 2.
- Goal: Identify the minimum medication necessary to maintain control 1.
Essential Non-Pharmacologic Components
Patient Education & Self-Management
- Provide a written asthma action plan to every patient, including daily controller regimen, criteria for stepping up therapy (symptoms worsening or peak flow <80% personal best), when to start oral corticosteroids (peak flow <60% personal best), and emergency care triggers (peak flow <50% after treatment) 1, 2.
- Teach proper inhaler technique at every visit; start with metered-dose inhaler (MDI) plus spacer and verify technique 2.
- Educate on medication roles: distinguish daily controller medications from as-needed quick-relief agents 2.
Allergy Testing & Environmental Control
- Perform skin testing or specific IgE for perennial indoor allergens (dust mite, cockroach, cat, dog, mold) in all patients requiring daily medication 2.
- Implement multi-component allergen reduction for identified sensitivities; single interventions are ineffective 2.
- Eliminate tobacco smoke exposure completely; counsel cessation at every visit 2.
Comorbidity Management
- Allergic rhinitis/sinusitis: intranasal corticosteroids and antihistamines 2.
- GERD: dietary modifications, head-of-bed elevation, proton-pump inhibitor 2.
- Obesity: weight-loss interventions may improve control 2.
- Obstructive sleep apnea: evaluate in overweight/obese patients with poor control 2.
- Anxiety/depression: address with self-management education and coping strategies 2.
Monitoring Schedule
- Initial visit (2–4 weeks after therapy start): Assess lung function (spirometry), symptom control (ACT/ACQ), and inhaler technique 2.
- While gaining control: Review every 1–6 weeks 2.
- Once controlled: Review every 1–6 months, depending on treatment step 2.
- Spirometry: Perform at least every 1–2 years; more frequently if control is suboptimal 2.
Common Pitfalls to Avoid
- Do not diagnose asthma on symptoms alone; objective spirometry demonstrating reversible airflow obstruction (FEV₁ increase ≥12% and ≥200 mL after bronchodilator) is required 2.
- Do not accept frequent SABA use (>2 days/week) as normal; this indicates need for initiating or intensifying controller therapy 1, 2.
- Never prescribe LABA without concurrent ICS; LABA monotherapy increases mortality risk 2.
- Do not step up therapy without first confirming adherence, technique, environmental control, and comorbidity management 2.
- Do not assume well-controlled baseline asthma protects against severe exacerbations; patients at any severity level can experience life-threatening episodes 4.
Specialist Referral Indications
Refer to pulmonology or allergy specialist when 2:
- Patient requires Step 4 or higher (medium-to-high dose ICS-LABA).
- ≥2 oral corticosteroid courses in the past year.
- Hospitalization for asthma exacerbation occurs.
- Control remains unattainable despite optimized therapy.
- Consideration of biologic therapy (omalizumab, mepolizumab, etc.) or allergen immunotherapy.