Management of Persistent Asthma – Controller and Rescue Therapy Recommendations

Definition and Indications

• Persistent asthma is defined by ≥2 exacerbations within 3 months, and such patients should not be treated with short‑acting bronchodilators alone. 2
• Use of a short‑acting β₂‑agonist (SABA) on >2 days per week for symptom relief signals inadequate control and the need to initiate or intensify anti‑inflammatory therapy. 2

Controller (Daily Inhaled Corticosteroid)

• Daily low‑dose inhaled beclomethasone (≈80–250 µg beclomethasone‑equivalent) administered twice daily is recommended for all patients with persistent asthma, regardless of day‑to‑day symptoms. [1][2]
• This regimen is considered the gold‑standard for preventing future exacerbations and should be started promptly. [1][2]

Rescue (Short‑Acting β₂‑Agonist)

• Albuterol (salbutamol) 100–180 µg per inhalation should be used only as needed for acute symptom relief; it must not be prescribed on a scheduled or chronic daily basis. 2
• Patients requiring SABA use on >2 days per week should have their controller therapy intensified. 2

Emerging As‑Needed Combination Therapy (Conditional Recommendation)

• For mild persistent asthma in patients ≥ 12 years, an as‑needed combination of albuterol followed immediately by beclomethasone (2–4 albuterol inhalations + 80–250 µg beclomethasone every 4 hours as needed) is an alternative to daily inhaled corticosteroid. 1
• Controlled studies show efficacy comparable to daily beclomethasone, but the recommendation is conditional with moderate certainty of evidence. 1

Monitoring and Follow‑Up

• Advise patients to rinse the mouth after each beclomethasone inhalation to reduce systemic absorption and the risk of oral candidiasis. 2
• Schedule regular follow‑up (e.g., every 4–6 weeks) to assess asthma control and adjust therapy as needed. 1

Practical Implementation for a Patient with 2 Exacerbations in 3 Months

• Initiate beclomethasone 100–250 µg twice daily (morning and night). [1][2]
• Maintain albuterol 100–180 µg for rescue only (use during acute symptoms). 2
• Reevaluate asthma control in 4–6 weeks to determine if dose adjustment is required. 1
• Provide education on correct inhaler technique and the distinction between controller and rescue medications. 2