Asthma Treatment Steps
Recommended for infrequent asthma symptoms (less than twice a month) and no risk factors for exacerbations. The preferred initial treatment for adults and adolescents is the combination of inhaled corticosteroid (ICS) and formoterol (long-acting β2-agonists (LABA)), another option is taking ICS whenever short-acting β2-agonists (SABA) is taken. Formoterol (LABA) exhibits rapid onset of action as SABA so it can be used as a reliever. Taking SABA alone is no longer recommended due to an increased risk of asthma-related death. For children aged 6-11 years, the recommended controller therapy is taking ICS whenever SABA is taken, and another option is to take regular ICS with as-needed SABA. For children aged 5 years and younger, taking as-needed SABA is the first choice, but the use of SABA, on average more than twice a week over one month indicates the need for controller therapy. Another option is intermittent high dose ICS, when inhaled SABA is insufficient for children with intermittent viral-induced wheeze, especially if atopic.
Before stepping up, it is essential to check for poor adherence, incorrect inhaler technique, or persistence of modifiable risk factors for asthma exacerbations.
Recommended for frequent asthma symptoms (twice a month or more). For adults and adolescents, the preferred treatment is daily low dose ICS with as-needed SABA or as-needed low dose ICS-formoterol used to relieve symptoms or to prevent exercise-induced bronchoconstriction. Other options; if as-needed ICS-formoterol is not available, taking low dose ICS whenever SABA is taken is also an efficient controller. Leukotriene receptor antagonists (LTRA) are less effective than ICS; however, in some cases suffering from intolerable side effects of ICS or allergic rhinitis, LTRA can be used as an alternative. For children (6-11 years), the use of regular daily low dose ICS with as-needed SABA is the preferred choice. Other options include: receiving daily LTRA or taking low dose ICS whenever SABA is needed. For children aged 5 years or younger, the preferred option is regular daily low dose ICS with as-needed SABA. Other options; if asthma symptoms persist, regular treatment with LTRA decreases symptoms and the need for oral corticosteroids; however, this is not the case in children with recurrent viral-induced wheezing.
Recommended for persistent asthma symptoms most days or waking due to asthma once a week or more. For adults and adolescents, the preferred controller options are low dose ICS-LABA as controller therapy with as-needed SABA as reliever or low dose ICS-formoterol as both controller and reliever therapy. Other options; increasing ICS to medium dose, but it has been proved that adding LABA to low dose ICS is more effective. Low dose ICS plus either LTRA or low dose sustained-release theophylline have been proved to be less effective. For children (6-11 years), it is preferred to increase ICS to medium dose or use the combination low dose ICS-LABA. For children aged 5 years or younger, additional controller treatment with as-needed SABA and consider specialist referral. The preferred option is medium-dose ICS with as-needed SABA; another option is the addition of LTRA to low dose ICS.
Recommended for initial presentation with an acute exacerbation or severely uncontrolled asthma. For adults and adolescents, the preferred controller is low dose ICS-formoterol as controller and reliever or medium-dose ICS-LABA as a controller with as-needed SABA as a reliever. Although low dose ICS is most beneficial, some cases require a medium dose, but high doses are no longer recommended—other options; tiotropium (used as add-on treatment). Medium dose ICS with LABA twice daily is more effective than adding LTRA or low dose sustained-release theophylline. For children (6-11 years), the preferred choice is medium-dose ICS-LABA as a controller with as-needed SABA as a reliever. Other options; increasing ICS-LABA to the high pediatric dose. Tiotropium may be used as add-on therapy, LTRA could be added, but theophylline is not recommended. . For children aging 5 years or younger, continue the controller treatment and refer the child for expert advice and further investigations.
Patients inadequately controlled despite good adherence to step 4 treatment should be referred to specialist to assess their condition regarding asthma phenotype and possible add-on therapies including new immunological treatment options.
Personalized asthma management is done through initial assessment of patient condition, continuing adjustment of treatment, with review of patient response every 2-3 months or even earlier.
Non-pharmacological strategies regarding reduction of risk factors, avoidance of asthma triggers and breathing exercises should be considered.
Patient training on inhaler skills and encouraging adherence are also crucial. (GINA., 2020)