Asthma: The Stepwise Approach to Treatment
Table of Contents
CLINICAL ACTIONS:
Because asthma is an inherently variable condition, therapy should be reassessed at each visit. Management is a dynamic process that will change based on the patient’s needs over time.
- Effective asthma management requires a proactive, preventative and stepwise approach
- Control of asthma is viewed in the context of impairment and risk
Reducing Impairment
- Prevent chronic symptoms (troublesome cough, shortness of breath)
- Limited SABA use (<3 x200-dose canisters annually)
- Maintain (near) normal pulmonary function
- Maintain normal activity levels including
- Exercise and other physical activity
- Attendance at work or school
Reducing Risk
- Teach patients to monitor their symptoms
- Advise patients to quit smoking/vaping and to avoid other people’s smoke/vapes.
- Advise appropriate food allergen avoidance and ensure patients have injectable epinephrine for anaphylaxis
- Encourage regular physical activity
- Investigate for occupational asthma by asking about work history
- Always ask about previous reactions before prescribing NSAIDs to avoid aspirin-exacerbated respiratory distress
- Use ASTHMA ACTION PLAN (see ‘Learn More – Primary Sources’ below) or other management plan to
- Prevent recurrent exacerbations
- Minimize the need for ED visits or hospitalizations
- Prevent progressive loss of lung function
- Provide optimal pharmacotherapy with minimal or no adverse effects
SYNOPSIS:
Treatment should be individualized in a ‘stepwise’ fashion. The guidelines note that “The stepwise approach is meant to help, not replace, the clinical decision making needed to meet individual patient needs.” If a patient remains stable for 3 months, reducing medications in a ‘step down’ approach can be used. In addition, two key factors to a successful outcome are patient education and measures to control environmental triggers and comorbidities.
KEY POINTS:
Treatment
Note: Before moving on from one step to the next, review the following:
- Watch patient using their inhaler and discuss barriers to adherence/use
- Confirm the diagnosis of asthma
- Reduce potential risk factors and assess/manage comorbidities
- Consider short-term treatment step-up
- Refer to expert if asthma is still uncontrolled after 3-6 months of Step 4 treatment (outlined below).
Step 1
- Clinical features: Infrequent asthma symptoms (<1-2 days per week)
- Preferred treatment: Treat with low-dose ICS-formoterol as needed. Do NOT prescribe a SABA alone, even to use as needed.
Step 2
- Clinical features: Asthma symptoms less than 3-5 days/week with normal or mildly reduced lung function
- Preferred treatment: Lose-dose ICS-formoterol taken as needed
Step 3
- Clinical features: Asthma symptoms most days, waking due to asthma once a week or more, or low lung function
- Preferred treatment: Lose-dose ICS-formoterol maintenance-and-reliever therapy (MART)
Step 4
- Clinical features: Daily asthma symptoms, waking at night with asthma once a week or more, with low lung function, or current smokers
- Preferred treatment: Medium-dose ICS-formoterol MART
Step 5
- Clinical features: Uncontrolled symptoms and/or exacerbations despite Step 4 treatment
- Preferred treatment: Add-on LAMA, refer for assessment of phenotype, consider trial of high-dose maintenance ICS-formoterol, and/or consider anti-IgE, anti-IL5/5R, anti-IL4Ra and anti-TSLP therapies.
Medications
SABAs
- Salbutamol (albuterol) | terbutaline
- Delivery via inhaled pressurized metered-dose inhaler, dry-powder inhalation, or nebulizer
- Can be used for quick relief of asthma symptoms and bronchoconstriction and for pretreatment before exercise.
- Should not be used without ICS due to increased risk of severe exacerbations and asthma-related death
- Short-term adverse effects: tremor, tachycardia
- With regular/frequent use, adverse effects: tolerance results in increased airway hyperrespoinsiveness, reduced bronchodilator effect, and increased airway inflammation
Short-Acting Antimuscarinic Antagonists (anticholinergics)
- Ipratropium bromide | oxitropium bromide
- Delivery via inhaler pressured metered-dose inhaler, dry powder, or nebulizer
- Can be used in combinations with a SABA for acute care of severe exacerbations
- Adverse effects: dry mouth, bitter taste. Use with caution in patients with narrow-angle glaucoma
ICSs
- Beclomethasone | Budesonide | Ciclesonide | Fluticasone propionate | Mometasone | Triamcinolone acetonide
- Most effective anti-inflammatory medications for asthma (reduce symptoms, increase lung function, reduce airway hyperresponsiveness, improve quality of life, and reduce the risk of exacerbations, asthma-related hospitalizations and death.
- Local adverse effects: oropharyngeal candidiasis, dysphonia
- Systemic adverse effects: osteoporosis, cataracts, glaucoma with long-term use
- ICS are often combined with other medications, as explained below
Low-Dose Combination ICS-formoterol
- Beclomethasone-formoterol | budesonide-formoterol
- Used as the reliever (without maintenance therapy) for adults with at Step 1 of plan above
- Can also be used for maintenance-and-reliever therapy (MART)
- Can be used before exercise to prevent exercise-induced bronchoconstriction
Low-Dose Combination ICS-SABA
- Budesonide-salbutamol (albuterol) | beclomethasone-salbutamol
- Should be used as an acute symptom reliever (instead of SABA)
- Cannot be used as MART
ICS in Combination with a Long-Acting Beta2-Agonist (ICS-LABA)
- Beclomethasone-formoterol | budesonide-formoterol | fluticasone furoate-vilanterol | fluticasone propionate formoterol | fluticasone propionate-salmeterol | mometasone-formoterol | mometasone-indacaterol
- Delivered via inhaled pressured meter-dose inhaler or dry-powder inhaler
- Can be used as maintenance-and-reliever therapy (MART) or in combination with SABA as a reliever, but first option is preferred.
- Adverse effects of LABA: tachycardia, headaches, muscle cramps
Long-Acting Muscarinic Antagonists (LAMA)
- Tiotropium
- Can be added to ICS-LABA treatment for patients with continued uncontrolled symptoms
- Adverse effects are uncommon: dry mouth, urinary retention
Anti-Immunoglobulin E
- Omalizumab
- Delivery via subcutaneous injection
- Can be added to treatments plans above for severe uncontrolled allergic asthma already on high-dose ICS-LABA
- Adverse effects: minor reactions at injection site, anaphylaxis (very rare)
Anti-Interleukin 5 and Anti-Interleukin 5 Receptor Alpha
- Benralizumab | reslizumab
- Delivery via subcutaneous injection or IV infusion
- Adverse effects: headaches, minor reactions at injection site
Systemic Oral Corticosteroids
- Prednisone | prednisolone | methylprednisolone | hydrocortisone | dexamethasone
- Delivery via oral tablets/liquid, IM injection or IV injection
- Used for short-term relie of severe acute exacerbations, typically no more than 5-7 days.
- Avoid for long-term use due to serious adverse effects
Managing Acute Exacerbations Requiring Emergency Care
- Assess severity of the exacerbation while starting a SABA and oxygen
- Severe symptoms include talking in single words, sitting hunched forward, or using accessory respiratory muscles
- Check for anaphylaxis and assess vitals
- Severe symptoms include respiratory rate >30, pulse > 120 bpm, SpO2<90%
- Consider alternative causes of acute dyspnea
- Arrange immediate transfer to an acute care facility
- Schedule follow up visits
- Every 1-3 months after starting treatment
- Every 3-12 months for maintenance control
- If asthma has been well controlled for 3 months or more, consider stepping down therapy
- Treat comorbid conditions and assess vaccination status
- Inactivated flu vaccine yearly
- Pneumococcal vaccine PPSV23
- 19 to 64 years: 1 dose
- ≥65 years: One final dose at least five years following previous dose
- Zoster vaccine
- Tdap vaccine
Schedule Follow Up Visits
- Every 1 to 3 months after starting treatment
- Every 3 to 12 months for maintenance control
- If asthma has been well controlled for 3 months or more, consider stepping down therapy
Treat Comorbid Conditions and Assess Vaccination Status
- Inactivated flu vaccine yearly
- Pneumococcal vaccine PPSV23
- 19 to 64 years: 1 dose
- ≥65 years: One final dose at least five years following previous dose
- Zoster vaccine
- Tdap vaccine
Pregnancy
- Check asthma control at all prenatal visits and adjust medications as needed
- Treatment safer for both mother and fetus vs uncontrolled asthma
- Avoid exposure to tobacco smoke
Learn More – Primary Sources:
GINA: Global Strategy for Asthma Management and Prevention (2025 update)
US DOH: Focused Updates to the Asthma Management Guidelines (2020)
