Management approach The main goal of treatment is to achieve maximum control of symptoms with the fewest medications. Asthma control refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Optimal control should include assessment of a combination of the patient's symptoms and the PFTs. The goal for optimal control is to have the patient asymptomatic with normal PFTs if possible. Once a state of control is achieved, an attempt should be made to reduce the doses of medications while maintaining optimal control and minimising any adverse effects. Stepwise therapy for long-term management Guidelines recommend that asthma severity and control be viewed as a ladder in which medication can be stepped up or stepped down based on the severity of the disease and adequacy of the control: for example, as determined by asthma control test. The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. Patients may start at any step of the ladder, and medications can be added (stepped up) if needed. Increasing use of a short-acting beta agonist (SABA) or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment. Regular assessment of patient's asthma control should be carried out with the aim of stepping down the ladder if disease has been well controlled for at least 3 months. Education and environmental control All patients at all steps of therapy should receive adequate patient education and should take environmental control measures. Exercise-induced asthma Exercise-induced symptoms may occur in around 50% to 65% of people with asthma. Inhaled corticosteroids (ICS) have been shown to significantly reduce the severity of exercise-induced asthma. Sodium cromoglicate, nedocromil sodium, or a bronchodilator can be used immediately before exercise (or as rescue medication) until the full effect of ICS is realised. Other medications include long-acting beta-agonists used in combination with ICS, which can be used successfully for prevention of exercise-induced asthma in patients with abnormal spirometry and/or more persistent symptoms. Leukotriene receptor antagonists are also used to control exercise-induced asthma and provide 50% to 60% protection when given as tablets for up to 24 hours Allergen immunotherapy For well-controlled confirmed allergic asthma, treatment with allergen immunotherapy is an option. This treatment is only used with documented allergies either by skin testing or specific IgE serology and should only be given with adequate supervision to prevent adverse systemic allergic reactions. Step 1: mild intermittent and exercise-induced asthma Defined as: Symptoms ≤2 times a week Asymptomatic and normal peak expiratory flow rate (PEFR) between attacks Attacks are brief with varying intensity Night-time symptoms ≤2 times a month Forced expiratory flow at 1 second (FEV1) or PEFR ≥80% of predicted PEFR variability <20%. For those patients with mild intermittent asthma or exercise-induced asthma, the use of a SABA on an 'as required' basis is sufficient alone.[B Evidence] All patients should have access to quick-relief SABAs. Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment. Step 2: mild persistent Defined as: Symptoms >2 times a week but <1 time a day Exacerbations may affect activity Night-time symptoms >2 times a month FEV1 ≥80% of predicted PEFR variability between 20% and 30%. A low-dose inhaled corticosteroid (ICS) is added if control is not achieved with a SABA used on an 'as needed' basis only. [B Evidence] Second-line options that can be used instead of a low-dose ICS are sodium cromoglicate or nedocromil, a leukotriene-receptor antagonist (LTRA), [B Evidence] or theophylline. All patients should have access to quick-relief SABAs. Step 3: moderate persistent Defined as: Daily symptoms Use of short-acting beta agonists daily Attacks affect activity Exacerbations ≥2 times a week and may last for days Night-time symptoms >1 time a week FEV1 >60% to <80% of predicted PEFR variability >30%. Adds a long-acting beta agonist (LABA) to a low-dose ICS, or increases the dose of the ICS to a medium-dose range.[B Evidence] LABA monotherapy should not be given in asthma due to the risk of serious asthma-related events (asthma-related death, intubation, and hospitalisation). Second-line alternatives to either increasing the ICS dose or adding an LABA are to combine a low-dose ICS with either an LTRA, [B Evidence] theophylline,[C Evidence] or zileuton. All patients should have access to quick-relief SABAs. Steps 4 to 6: severe persistent Defined as: Continual symptoms Limited physical activity Frequent exacerbations Frequent night-time symptoms FEV1 ≤60% of predicted PEFR variability >60%. Preferred combination treatment for step 4 is a medium-dose ICS plus a long-acting bronchodilator. A long-acting bronchodilator can be substituted with either an LTRA, theophylline, or zileuton. Addition of tiotropium to an ICS has been shown to improve symptoms and lung function in patients with inadequately controlled asthma. Its effects appear to be equivalent to those seen with the addition of salmeterol. Addition of tiotropium may also decrease the risk of severe exacerbations. Step 5 changes a medium-dose ICS to a high-dose ICS. The US National Institutes of Health (NIH) guidelines recommend high doses of ICS in adults with severe persistent asthma. There are no maximum doses for high-dose inhaled corticosteroid therapy reported in the guidelines. Therefore, the dose should be increased gradually and cautiously according to patient response and adverse effects. At these high doses, adrenal suppression is likely; therefore, specialist pulmonary assessment should be sought before initiating this type of therapy. It should be noted that the manufacturer's recommended maximum dose is lower than the doses suggested in the guidelines. An immunomodulator (i.e., omalizumab) can be considered in patients with allergies. Step 6 adds oral corticosteroids to existing treatments. All patients should have access to quick-relief SABAs. Source
