What are the features of each step in a stepwise approach to pharmacotherapy in the treatment of asthma according to the guidelines?

Updated: Jan 07, 2019
  • Author: Michael J Morris, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change. The 2007 NAEPP guidelines offer the recommendations below. [1]

Step 1 for intermittent asthma is as follows:

  • Controller medication not indicated
  • Reliever medication is a short-acting beta-agonist (SABA) as needed for symptoms

Step 2 for mild persistent asthma is as follows:

  • Preferred controller medication is a low-dose inhaled corticosteroid
  • Alternatives include cromolyn, leukotriene receptor antagonist (LTRA), [109] or theophylline

Step 3 for moderate persistent asthma is as follows:

  • Preferred controller medication is either a low-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA) (combination medication preferred choice to improve compliance) [110] or an inhaled medium-dose corticosteroid
  • Alternatives include an low-dose ICS plus either a LTRA or theophylline

Step 4 for moderate-to-severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled medium-dose corticosteroid plus a LABA (combination therapy)
  • Alternatives include an inhaled medium-dose corticosteroid plus either an LTRA or theophylline

Step 5 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA

Step 6 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA plus oral corticosteroid

The 2016 GINA guidelines include the following stepwise recommendations for medication and symptom control [106] :

  • Step 1: As-needed SABA with no controller; other options are to consider low-dose ICS for patients with exacerbation risks
  • Step 2: Regular low-dose ICS plus as-needed SABA; other options are LTRA or theophylline
  • Step 3: Low-dose ICS/LABA plus as-needed SABA or ICS/formoterol maintenance and reliever therapy; other options are medium-dose ICS or low-dose ICS/LABA
  • Step 4: Low-dose ICS/formoterol maintenance and reliever therapy or medium-dose ICS/LABA as maintenance plus as-needed SABA; add-on tiotropium for patients with history of exacerbations; other options are high-dose ICS/LTRA or slow-release theophylline; refer for expert assessment and advice
  • Step 5: Refer for expert investigation and add-on treatment; add-on treatments include tiotropium by mist inhaler for patients with a history of exacerbations, omalizumab for severe allergic asthma, and mepolizumab for severe eosinophilic asthma; other options are that some patients may benefit from low-dose oral corticosteroids but long-term systemic adverse effects occur

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