Step 1 | Step 2 | Step 3 | Step 4 | ||
Qualifying criteria | All of the following at initiation of therapy or using SABA alone:
| Any of the following:
| Any of the following:
| Any of the following:
| |
Option 1 | ICS-formoterol regimen | Low-dose ICS-formoterol* as needed | Low-dose ICS-formoterol* as needed | Low-dose ICS-formoterol as maintenance and reliever therapy (preferred)¶ | Medium-dose ICS-formoterol as maintenance and reliever therapy (preferred)¶ |
Option 2 | Alternative maintenance regimens | (No maintenance regimen) | (Anti-inflammatory reliever therapy without a maintenance regimen)*Δ or Low-dose ICS (daily or twice daily) | Low-dose ICS-LABA (preferred alternative) or Low-dose ICS plus LAMA or LTRA | Medium-dose ICS-LABA (preferred alternative) or Medium-dose ICS plus LAMA or LTRA |
and | and | and | and | and | |
Alternative reliever regimens | ICS-SABA as needed* or ICS plus SABA as needed* or SABA, as needed | ICS-SABA as needed*Δ or ICS plus SABA as needed*Δ or SABA, as needed | ICS-SABA as needed* or ICS plus SABA as needed* or SABA, as needed | ICS-SABA as needed* or ICS plus SABA as needed* or SABA, as needed |
This table illustrates simplified recommendations for initiating asthma therapy based on the frequency and severity of asthma symptoms. This table may also be used to guide therapeutic adjustments in patients using SABA alone (without any controller therapy). The response to therapy should be assessed in 2 to 12 weeks depending on clinical urgency. At follow-up visits, check adherence, inhaler technique, environmental factors, and comorbid conditions. Subcutaneous immunotherapy is suggested as an adjunct to standard pharmacotherapy in individuals who have demonstrated allergy to the included allergens and whose asthma is well controlled whenever immunotherapy is administered. Consult with an asthma specialist for patients not controlled on step 4 therapy.
Additional strategies for ongoing asthma treatment may be found in the accompanying graphic on guideline approaches to initial asthma therapy. Dosing information can be found in separate dosing tables for SABA, AIR, MART, inhaled glucocorticoids, and inhaled glucocorticoids combined with bronchodilators. For additional information, please refer to UpToDate content on initial and ongoing treatment of asthma in adolescents and adults.AIR: anti-inflammatory reliever; DPI: dry powder inhaler; FEV1: forced expiratory volume in one second; ICS: inhaled corticosteroid (glucocorticoid); IgE: immunoglobulin E; IL: interleukin; LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; LTRA: leukotriene receptor antagonist; MART: maintenance and reliever therapy; MDI: metered-dose inhaler; SABA: short-acting beta-agonist.
* When prescribed for use as-needed for acute asthma symptoms, ICS-formoterol, ICS-SABA, and concomitant ICS and SABA use are referred to as AIR therapy. Compared with SABA relievers, use of AIR has demonstrated decreased exacerbation risk in patients with all degrees of asthma severity. Choice of therapy is also guided by patient preference, cost, and medication availability. LABAs other than formoterol cannot be used for AIR due to their more prolonged onset of action. Patients with risk factors for exacerbations, variable symptoms, or poor adherence to maintenance therapies are particularly likely to benefit from AIR, but choice of therapy is also guided by patient preference, cost, and medication availability.
Risk factors for exacerbations include: poor asthma symptom control, a history of asthma exacerbation on the current regimen, smoking, allergen exposure if sensitized, previous intubation or intensive care unit stay for asthma, low FEV1 (especially <60% predicted), obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique. Please refer to UpToDate asthma treatment content and separate graphic on risk factors for asthma exacerbation for additional information.
¶ ICS-formoterol prescribed for use as both maintenance therapy and for acute relief of symptoms is referred to as MART. MART has been shown to be more effective in terms of exacerbation reduction and symptom relief compared with ICS-formoterol and SABA alone as reliever therapy. Choice of therapy is also guided by patient preference, cost, and medication availability. LABAs other than formoterol cannot be used for MART due to their more prolonged onset of action.
Δ For patients qualifying for step 2 therapy, only AIR (ICS-formoterol, ICS-SABA, and concomitant ICS and SABA) should be used without concomitant maintenance low-dose inhaled glucocorticoid therapy. These patients should not be treated with SABA alone.Do you want to add Medilib to your home screen?