Asthma Management Guidelines

Introduction to Step 5 Care

For patients requiring step 5 care in asthma management, the preferred treatment is high-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA), with options including fluticasone/salmeterol (Advair) and budesonide/formoterol (Symbicort) 1, 2

Fluticasone/Salmeterol (Advair) is available in high-dose formulation, administered twice daily, with strong evidence for efficacy in reducing exacerbations and improving lung function 1, 2
The American Academy of Family Physicians recommends Fluticasone/Salmeterol (Advair) as a treatment option for patients with asthma, with strong evidence for efficacy in reducing exacerbations and improving lung function 1

High-dose ICS is defined as: Beclomethasone HFA: >480 mcg daily, Budesonide DPI: >1200 mcg daily, Mometasone DPI: >400 mcg daily, Fluticasone: varies by formulation 3

Assess current control and adherence, and choose appropriate high-dose ICS/LABA based on patient preference for dosing frequency and need for rescue therapy with same device 1
Consider device type, with DPI (dry powder inhaler) preferred for most adults with adequate inspiratory flow, and MDI (metered dose inhaler) with spacer if inspiratory flow is limited 4

LABAs should never be used as monotherapy for asthma control due to increased risk of asthma-related deaths, and should always be combined with ICS, as recommended by the American Academy of Allergy, Asthma, and Immunology 5, 3
Monitor for oral thrush, dysphonia, and cough with high-dose ICS, and advise patients to rinse mouth after using ICS to reduce risk of oral candidiasis 3
After initiating high-dose ICS/LABA therapy, assess symptom control after 2-4 weeks, and consider stepping down therapy if control is maintained for at least 3 months 3

For patients with severe persistent asthma not controlled on high-dose ICS/LABA, consider adding omalizumab for those with allergies, as recommended by the American Academy of Family Physicians 1