Treatment of Moderate Persistent Asthma

First-Line Treatment Options

The American College of Allergy, Asthma, and Immunology recommends low-to-medium-dose inhaled corticosteroids (ICS) plus long-acting beta2-agonists (LABA) as the preferred treatment for moderate persistent asthma in adults and children older than 5 years, with strong evidence consistently showing improved outcomes 1, 2
The combination of low-to-medium-dose ICS plus LABA provides superior control of symptoms, improved lung function, and reduced exacerbation rates compared to other treatment options 3, 4
Budesonide/formoterol (Symbicort) can be used as both maintenance and reliever therapy (SMART protocol) for patients ≥12 years old 4
For children younger than 5 years, medium-dose ICS as monotherapy is a preferred option 3, 5

Increasing inhaled corticosteroids within medium-dose range is less effective than adding LABA 3
Low-to-medium-dose ICS plus leukotriene modifier (e.g., montelukast) is an alternative treatment option 3, 5
Low-to-medium-dose ICS plus theophylline is a less preferred option due to its side effect profile 3, 5

For patients with recurring severe exacerbations, increasing ICS within medium-dose range and adding a LABA is a recommended approach 3, 5
An alternative approach for these patients is to increase ICS within medium-dose range and add either leukotriene modifier or theophylline 3, 5

LABA should never be used as monotherapy for asthma due to increased risk of asthma-related events including deaths 4
Always combine LABA with ICS to mitigate this risk 4
Formoterol-containing combinations are preferred for SMART protocol due to rapid onset of action 4

If moderate persistent asthma is not controlled with the above regimen, consider increasing to medium-to-high-dose ICS/LABA 6, 4
For severe persistent asthma, high-dose ICS plus LABA, with addition of oral corticosteroids if needed, is a recommended approach 3, 5