Asthma Management

Initial Treatment and Assessment

• For patients with asthma who require daily albuterol use, the most appropriate treatment is to add a low-to-medium dose inhaled corticosteroid (ICS) as controller therapy, or to switch to a combination of ICS plus long-acting beta-agonist (LABA) if symptoms remain uncontrolled, as recommended by the European Respiratory Society and the American Academy of Allergy, Asthma, and Immunology 1, 2
• Need for SABA more than twice weekly for symptom relief indicates inadequate control, according to the American Academy of Family Physicians 3
• Daily albuterol use suggests at least mild persistent asthma, possibly moderate to severe depending on other symptoms, as stated by the American Academy of Allergy, Asthma, and Immunology 2
• Asthma severity should be determined using both domains of impairment and risk, and regularly monitoring asthma control to determine whether therapy should be maintained or adjusted, as recommended by the American Academy of Allergy, Asthma, and Immunology, with a strength of evidence based on expert opinion 2

Treatment Escalation

• The combination of low-to-medium dose ICS plus LABA is the preferred treatment for moderate persistent asthma, as recommended by the American Academy of Allergy, Asthma, and Immunology 4
• Increase ICS to medium-dose range and add LABA, or alternative: Increase ICS within medium-dose range and add either leukotriene modifier or theophylline, as suggested by the American Academy of Allergy, Asthma, and Immunology 4
• Common ICS options for first-line therapy include:

5

• Leukotriene modifiers can be considered as alternative add-on therapy if LABAs cannot be used, as recommended by the American Academy of Allergy, Asthma, and Immunology 6

Guideline Recommendations

• The Global Initiative for Asthma (GINA) guidelines clearly establish that patients requiring daily SABA use should not continue with SABA monotherapy, as stated by the European Respiratory Society 1
• The 2020 NAEPP guidelines conditionally recommend either daily low-dose ICS with as-needed SABA, or as-needed ICS and SABA used concomitantly for patients with mild persistent asthma, as recommended by the National Asthma Education and Prevention Program 7
• Inhaled corticosteroids (ICS) are the most effective long-term control medications across all age groups, according to the American Thoracic Society, with a high strength of evidence 2
• Combination therapy with ICS plus long-acting beta-agonists (LABA) is the preferred treatment option for moderate to severe persistent asthma, resulting in improved symptom scores, lower exacerbation rates, reduced symptom frequency, less use of supplemental short-acting beta2-agonists, fewer courses of oral systemic corticosteroids, and fewer hospitalizations 3

Special Populations

• Albuterol is the preferred SABA during pregnancy, with no evidence of fetal injury from short-acting inhaled beta2-agonists, as recommended by the American College of Obstetricians and Gynecologists 8
• For children aged 0-4 years with recurrent wheezing, consider starting a short course of daily ICS at the onset of respiratory infections with as-needed SABA, as recommended by the American Academy of Pediatrics 7
• For children aged 0-4 years, if no clear benefit is observed within 4-6 weeks of therapy, consider alternative diagnoses or adjusting therapy, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
• For children with persistent asthma where inhaled corticosteroids cannot be administered effectively, montelukast 4 mg chewable tablet once daily is an appropriate alternative therapy, according to the American Academy of Allergy, Asthma, and Immunology, with effects seen within 24 hours of the first dose 4, 9

Acute Exacerbations

• Epinephrine is the primary treatment for anaphylaxis-related bronchospasm, with albuterol as an adjunct for persistent bronchospasm, as recommended by the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma, and Immunology 10, 11, 12
• Oxygen therapy is recommended for hypoxemic patients with asthma, according to the American Heart Association 13
• Systemic corticosteroids may be considered if bronchospasm persists, according to the American Academy of Allergy, Asthma, and Immunology 11
• Magnesium sulfate can be considered for IV administration in severe refractory exacerbations, as suggested by the American Heart Association 13
• Ipratropium bromide can be added to short-acting beta-agonists (SABA) for severe exacerbations, according to the American Heart Association 13

Monitoring and Adjustment

• Regular monitoring and adjustment of therapy based on control leads to better outcomes, as recommended by the American College of Chest Physicians, with a high strength of evidence 5
• The American Academy of Allergy, Asthma, and Immunology recommends scheduling follow-up at 1-6 week intervals while gaining control, and once control is achieved, follow-up at 1-6 month intervals, with a strength of evidence based on expert opinion 2
• Consider step-down after 3 months of good control, as suggested by the National Asthma Education and Prevention Program, with a moderate strength of evidence 2
• An objective response to treatment is defined as an improvement in FEV₁ of ≥10% predicted and/or >200 ml, as defined by the European Respiratory Society 14
• Consider referral to an asthma specialist if symptoms remain uncontrolled despite Step 3 therapy, patient has had ≥2 exacerbations requiring oral corticosteroids in the past year, patient requires Step 4 care or higher, or additional testing is needed, as recommended by the National Asthma Education and Prevention Program guidelines and the American Academy of Allergy, Asthma, and Immunology 2, 3

Patient Education

• A written asthma action plan should be developed for all patients, as recommended by the American Academy of Family Physicians 15
• Check inhaler technique and adherence before considering step-up, as recommended by the British Medical Journal 16
• Review adherence to medication and inhaler technique before stepping up therapy, as recommended by the American Academy of Allergy, Asthma, and Immunology 2
• The American Academy of Allergy, Asthma, and Immunology recommends pre-exercise warm-up to reduce exercise-induced bronchospasm (EIB) severity 17