Asthma Treatment Escalation

Assessment of Asthma Control

The American Academy of Allergy, Asthma, and Immunology recommends that symptoms occurring >2 days/week indicates not well-controlled asthma 2
The American Academy of Allergy, Asthma, and Immunology suggests that nighttime awakenings 1-3 times/week suggests inadequate control 2
The American Academy of Allergy, Asthma, and Immunology states that interference with normal activity indicates poor control 2
The British Medical Journal recommends that short-acting β2-agonist use >2 days/week for symptom control signals the need for treatment adjustment 1, 2
The American Academy of Allergy, Asthma, and Immunology recommends that FEV1 or peak flow 60-80% of predicted/personal best indicates not well-controlled asthma 2

The British Medical Journal recommends checking compliance with current medications before increasing therapy 1
The British Medical Journal suggests verifying proper inhaler technique before increasing therapy 1
The American Academy of Allergy, Asthma, and Immunology recommends assessing for environmental triggers contributing to worsening symptoms 3
The American Academy of Allergy, Asthma, and Immunology suggests stepping up to daily low-dose inhaled corticosteroids (ICS) when symptoms occur >2 days/week 2
The American Academy of Allergy, Asthma, and Immunology recommends adding a long-acting β-agonist (LABA) when asthma is not adequately controlled on low-dose ICS 3
The American Academy of Allergy, Asthma, and Immunology suggests increasing to medium-dose ICS plus LABA when control remains inadequate on low-dose ICS plus LABA 3
The American Academy of Allergy, Asthma, and Immunology recommends considering high-dose ICS plus LABA if symptoms persist on medium-dose ICS plus LABA 2

The American Thoracic Society recommends considering using biomarkers of type-2 airway inflammation to guide treatment decisions 5, 6
The British Medical Journal suggests considering a short course of oral corticosteroids for worsening symptoms with day-by-day deterioration of peak flow to below 60% of patient's best 1
The British Medical Journal recommends prednisolone 30-40 mg daily until lung function values return to previous best (typically 7-21 days) 1
The British Medical Journal suggests that a one to three month period of stability should be demonstrated before attempting to step down treatment 1

The American Thoracic Society warns that the stepwise approach may lead to inappropriately excessive doses of ICS, resulting in unnecessary systemic adverse effects 6
The American Thoracic Society recommends considering comorbidities as a potential cause of persistent symptoms 6
The American Academy of Allergy, Asthma, and Immunology emphasizes that asthma control involves both symptom management and reducing future risk of exacerbations 2
The American Academy of Allergy, Asthma, and Immunology recommends regular monitoring as asthma often varies over time 2
The American Academy of Allergy, Asthma, and Immunology warns that LABAs should never be used without ICS due to increased risk of asthma-related death 4