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5 Steps to Treat Asthma Patients

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Asthma Treatment Steps

Step 1:

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.

5 Steps to Treat Asthma Patients

Step 2:

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.

Step 3:

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.

Step 4:

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.

Step 5:

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)

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