How should I manage a patient with partially controlled bronchial asthma who is currently on low‑dose inhaled corticosteroid (ICS) alone or low‑dose inhaled corticosteroid/long‑acting β2‑agonist (ICS/LABA) therapy?

Management of Partially Controlled Bronchial Asthma

For patients with partially controlled asthma on low-dose ICS alone or low-dose ICS/LABA, add a long-acting β₂-agonist (LABA) to low-dose ICS if not already prescribed, or step up to medium-dose ICS/LABA combination therapy if already on low-dose ICS/LABA. 1

Initial Assessment Before Stepping Up Therapy

Before escalating treatment, verify three critical factors that commonly masquerade as treatment failure:

• Inhaler technique – incorrect technique is a leading cause of apparent uncontrolled asthma and must be assessed at every visit 1
• Medication adherence – poor adherence (≤75% of prescribed doses) increases risk of step-down failure by 23-fold and must be addressed before dose escalation 2
• Environmental trigger control – uncontrolled allergen exposure or irritants (smoking, occupational exposures) should be identified and mitigated 1

Step-Up Algorithm for Partially Controlled Asthma

If Currently on Low-Dose ICS Monotherapy

Add LABA to the existing low-dose ICS rather than increasing ICS dose alone. 1, 3 This combination approach:

• Reduces exacerbations requiring systemic corticosteroids from 11% to 9% (NNT = 38 over 48 weeks) 3
• Provides superior improvements in lung function, symptom control, and quality of life compared to doubling ICS dose 1, 3
• Addresses complementary pathophysiologic mechanisms – ICS suppresses chronic inflammation while LABA inhibits mast cell mediator release, plasma exudation, and provides bronchodilation 4

Preferred regimens:

• Fluticasone/salmeterol 100-250/50 mcg twice daily 1
• Budesonide/formoterol 200/6 mcg twice daily 1, 5

Critical safety warning: LABA must never be prescribed as monotherapy due to increased risk of asthma-related death and severe exacerbations. 1, 6, 3 Always use fixed-dose combination inhalers containing both ICS and LABA. 1

If Currently on Low-Dose ICS/LABA

Step up to medium-dose ICS/LABA combination therapy. 1, 7

Specific medium-dose regimens for adults and adolescents ≥12 years:

• Fluticasone/salmeterol 250/50 mcg twice daily 1, 7
• Budesonide/formoterol 400/6 mcg twice daily 7
• Beclomethasone/formoterol 200/6 mcg twice daily 7

The medium-dose range provides:

• Fluticasone propionate 250-500 mcg/day 7
• Budesonide 400-800 mcg/day 7
• Beclomethasone dipropionate 500-1000 mcg/day 7

Preferred Reliever Strategy (GINA 2024 Track 1)

Prescribe as-needed low-dose ICS-formoterol (budesonide-formoterol or beclomethasone-formoterol) as the reliever at all treatment steps. 1 This maintenance and reliever therapy (MART) approach:

• Reduces moderate-to-severe exacerbations compared to SABA-only rescue therapy 1, 8
• Provides both immediate bronchodilation and anti-inflammatory effect with each rescue use 1
• Is currently off-label; clinical data exist only for budesonide-formoterol and beclomethasone-formoterol 1

Alternative (if MART not feasible): As-needed short-acting β₂-agonist (SABA) such as albuterol 1

Monitoring and Reassessment Timeline

• Reassess control status every 2-6 weeks after initiating or changing therapy 1, 8
• Evaluate: symptom frequency, nighttime awakenings, SABA use, activity limitation, and objective lung function (FEV₁ or peak flow) 1

Well-controlled asthma criteria (all must be met):

• Daytime symptoms ≤2 days/week 1
• No nighttime awakenings 1
• SABA use ≤2 days/week (excluding pre-exercise use) 1
• No activity limitation 1
• FEV₁ or peak flow ≥80% predicted 1

When to Add Further Therapies

If asthma remains uncontrolled after 2-6 weeks on medium-dose ICS/LABA:

• Add long-acting muscarinic antagonist (LAMA) – tiotropium for patients ≥12 years 1
• Perform phenotypic assessment – measure blood eosinophils, FeNO, and allergen sensitization to identify treatable traits 1
• Consider biologic therapy if blood eosinophils are elevated (≥150/μl suggests type 2 inflammation) 1, 8
• Refer to pulmonology or allergy specialist when reaching Step 4 or higher therapy 1

Critical Pitfalls to Avoid

• Never use LABA as monotherapy – this increases risk of asthma-related mortality and severe exacerbations 1, 6, 3
• Do not ignore SABA overuse – using rescue inhaler >2 days/week indicates inadequate control and necessitates stepping up therapy 1, 8
• Do not escalate therapy without first verifying inhaler technique, adherence, and environmental trigger control 1, 2
• Avoid prolonged high-dose ICS – doses >500 mcg/day fluticasone equivalent increase risk of systemic adverse effects including osteoporosis, HPA axis suppression, and pneumonia 8
• Do not delay systemic corticosteroids during moderate-to-severe exacerbations, especially in patients with history of severe exacerbations 1

Risk Factors Requiring Immediate Step-Up

Step up immediately if any of the following are present:

• Any severe exacerbation in the past 12 months 1
• History of intubation or ICU admission for asthma 1
• High SABA use (>1 canister of 200 doses per month) 1
• FEV₁ <60% predicted 1
• Confirmed food allergy 1