How should I start an adult patient with persistent asthma on maintenance therapy?

Starting Maintenance Therapy for Adult Persistent Asthma

Begin with a low-dose inhaled corticosteroid (ICS) as the cornerstone of maintenance therapy for all adults with persistent asthma—specifically fluticasone propionate 100-250 mcg/day or budesonide 200-400 mcg/day administered twice daily, combined with an as-needed short-acting beta-agonist (SABA) for symptom relief. 1, 2

Initial Assessment Before Starting Therapy

Before initiating maintenance therapy, confirm the diagnosis and assess severity by evaluating:

• Symptom frequency: Daytime symptoms occurring more than 2 days per week indicate persistent asthma requiring daily controller therapy 3, 1
• Nighttime awakenings: Any nocturnal symptoms due to asthma suggest need for anti-inflammatory therapy 3
• SABA use: Using rescue inhalers more than 2 days per week for symptom relief (excluding pre-exercise use) indicates inadequate control and necessity for controller medication 3, 1
• Activity limitation: Any interference with normal daily activities warrants initiation of maintenance therapy 3

Step 2: Low-Dose ICS as First-Line Controller

Inhaled corticosteroids are the single most effective long-term control medication for persistent asthma, superior to all other monotherapy options including leukotriene modifiers, theophylline, or cromones. 1, 4, 5

Specific Dosing Regimens

Choose one of the following low-dose ICS options:

• Fluticasone propionate: 100-250 mcg/day divided into two doses 1, 2, 6
• Budesonide: 200-400 mcg/day divided into two doses 1, 2
• Beclomethasone dipropionate: 200-500 mcg/day divided into two doses 3, 2

Critical Delivery Technique

• Use a spacer or valved holding chamber with metered-dose inhalers to increase lung deposition from approximately 10% to 20-30% and reduce oropharyngeal side effects like thrush 1, 2
• Instruct patients to rinse mouth and spit after each inhalation to minimize local adverse effects including oral candidiasis and dysphonia 1, 2, 6

Step 3: When to Add Long-Acting Beta-Agonist (LABA)

If asthma remains uncontrolled after 2-6 weeks on low-dose ICS monotherapy, add a LABA to the existing low-dose ICS rather than increasing the ICS dose alone—this provides superior improvements in lung function, symptom control, and exacerbation reduction. 1, 2, 7

Preferred Combination Therapy Options

• Fluticasone/salmeterol: 100/50 mcg, 250/50 mcg, or 500/50 mcg twice daily depending on severity 3, 2, 6
• Budesonide/formoterol: 200/6 mcg twice daily 2

Critical Safety Warning About LABAs

LABAs must NEVER be used as monotherapy for asthma—this increases the risk of severe exacerbations and asthma-related deaths. LABAs must always be combined with ICS in a single combination inhaler or prescribed as separate inhalers used concurrently. 1, 2, 6

Alternative Controller Options (If ICS Cannot Be Used)

If ICS are not tolerated or contraindicated, consider these less effective alternatives:

• Leukotriene receptor antagonists: Montelukast 10 mg once daily for adults, or zafirlukast 20 mg twice daily 3, 2
• Cromolyn sodium or nedocromil: Alternative but not preferred options 3

These alternatives are significantly less effective than ICS and should only be used when ICS cannot be prescribed. 3, 1

Monitoring and Follow-Up Schedule

• Assess treatment response at 2-6 weeks after initiating therapy, evaluating symptom control, SABA use frequency, nighttime awakenings, and activity limitation 1, 2
• Schedule follow-up visits every 1-6 months depending on level of control and treatment step; more frequent monitoring is needed for poorly controlled asthma 3
• Verify proper inhaler technique at every visit, as poor technique is a common cause of apparent treatment failure 1, 8

Step-Up Algorithm When Control Is Inadequate

If asthma remains uncontrolled despite low-dose ICS after 2-6 weeks:

1. First, confirm adherence and proper inhaler technique before escalating therapy 3, 1
2. Assess and address environmental triggers including allergens, occupational exposures, and tobacco smoke 3
3. Add LABA to low-dose ICS (preferred step-up approach) 1, 2
4. Alternative: Increase to medium-dose ICS (250-500 mcg/day fluticasone equivalent) if LABA cannot be used 3, 7

Step-Down Strategy After Achieving Control

Once asthma control is sustained for at least 3 months, gradually reduce therapy to identify the minimum dose required to maintain control. 3, 1

• Reduce ICS dose by 25-50% every 3 months to the lowest effective dose 3
• Monitor closely for 2-6 weeks after each dose reduction to ensure sustained control 3

Common Pitfalls to Avoid

• Never delay initiating controller therapy when patients use SABAs more than twice weekly for symptom relief, as this indicates persistent asthma requiring anti-inflammatory treatment 1, 2
• Do not start with high-dose ICS, as the dose-response curve is relatively flat and starting with high doses provides no clinically meaningful advantage over low doses while significantly increasing systemic side effects 7, 9
• Never prescribe LABA without concurrent ICS, as LABA monotherapy dramatically increases mortality risk 1, 2, 6
• Do not assume poor control equals treatment failure without first verifying adherence, proper inhaler technique, and environmental control measures 3, 1
• Avoid unnecessarily high ICS doses when combination therapy with LABA at lower ICS doses is equally or more effective 1, 7

Managing Acute Exacerbations During Initiation

If the patient is experiencing an exacerbation at the time of assessment:

• Consider a short course of oral corticosteroids (prednisone 40-60 mg daily for 5-10 days without taper) to gain rapid control 3
• Initiate or continue maintenance ICS therapy concurrently with the oral steroid burst 3
• Reassess in 1-2 weeks after completing the oral steroid course 3