What is the first line therapy for Asthma (Bronchial Asthma)?

From the Guidelines

The first-line therapy for asthma is inhaled corticosteroids (ICS), which are recommended for all patients with persistent asthma symptoms. For mild intermittent asthma, as-needed use of a short-acting beta-agonist (SABA) like albuterol (2 puffs every 4-6 hours as needed) may be sufficient. However, for persistent asthma, low-dose ICS such as fluticasone (88-220 mcg twice daily), budesonide (180-360 mcg twice daily), or beclomethasone (40-80 mcg twice daily) should be used daily as controller therapy. These medications reduce airway inflammation, prevent symptoms, and decrease exacerbation risk, as supported by the expert panel report 3 (EPR-3) guidelines 1.

Key Points to Consider

• ICS are the most consistently effective long-term control medication at all steps of care for persistent asthma, and improve asthma control more effectively in both children and adults than leukotriene receptor antagonists (LTRAs) or any other single, long-term control medication 1.
• For patients with more severe symptoms, combination therapy with an ICS plus a long-acting beta-agonist (LABA) like fluticasone/salmeterol or budesonide/formoterol may be appropriate, as this combination is effective and safe when ICS alone are insufficient 1.
• Proper inhaler technique is crucial for medication effectiveness, and patients should rinse their mouth after ICS use to prevent oral thrush.
• Treatment should be regularly reassessed and stepped up or down based on symptom control, with the goal of achieving and maintaining control of symptoms while minimizing side effects and improving quality of life.

Additional Considerations

• The use of SABA more than two days per week or more than two nights per month generally indicates inadequate control of asthma and the need to initiate or intensify anti-inflammatory therapy 1.
• Oral systemic corticosteroids should be used to treat moderate to severe asthma exacerbations, as they can help to speed recovery and prevent recurrence of exacerbations 1.

From the FDA Drug Label

The precise mechanism of corticosteroid actions on inflammation in asthma is not well known. Inflammation is an important component in the pathogenesis of asthma Corticosteroids have been shown to have a wide range of inhibitory activities against multiple cell types (e.g., mast cells, eosinophils, neutrophils, macrophages, and lymphocytes) and mediators (e.g., histamine, eicosanoids, leukotrienes, and cytokines) involved in allergic- and non-allergic-mediated inflammation. The anti-inflammatory actions of corticosteroids may contribute to their efficacy in asthma

Asthma first line therapy is typically an inhalation corticosteroid (ICS), such as budesonide.

• Budesonide has been shown to have a favorable ratio between topical anti-inflammatory activities and systemic corticosteroid effects.
• The therapeutic effects of conventional doses of orally inhaled budesonide are largely explained by its direct local action on the respiratory tract.
• Improvement in the control of asthma symptoms following inhalation of budesonide can occur within 2 to 8 days of beginning treatment, although maximum benefit may not be achieved for 4 to 6 weeks 2

From the Research

Asthma First Line Therapy

• The first line therapy for asthma typically involves the use of inhaled corticosteroids (ICS) to control inflammation and prevent symptoms 3, 4.
• Low-dose inhaled fluticasone has been shown to be effective in reducing airway inflammation and improving lung function in patients with mild asthma 3.
• A study comparing low-dose and high-dose inhaled corticosteroids found that low-dose therapy was as effective as high-dose therapy in improving asthma control and reducing inflammation 4.
• Combination therapy with an ICS and a long-acting beta-agonist (LABA) is often used for patients with persistent asthma, and has been shown to be effective in improving symptoms and reducing exacerbations 5, 6, 7.

Comparison of Different Therapies

• A study comparing budesonide/formoterol with salmeterol/fluticasone propionate found that both therapies were effective in improving lung function and reducing symptoms, but that budesonide/formoterol may have an advantage in terms of reducing hospitalizations and emergency room visits 7.
• Another study found that switching from salmeterol/fluticasone to formoterol/budesonide improved peripheral airway/alveolar inflammation in patients with asthma 6.
• The choice of therapy may depend on individual patient factors, such as the severity of their asthma and their response to different medications 5, 7.

Key Findings

• Low-dose inhaled corticosteroids are effective in reducing airway inflammation and improving lung function in patients with mild asthma 3, 4.
• Combination therapy with an ICS and a LABA is effective in improving symptoms and reducing exacerbations in patients with persistent asthma 5, 6, 7.
• The choice of therapy should be individualized based on patient factors and response to treatment 5, 7.