Step 1 | Step 2 | Step 3 | Step 4 | Step 5* | ||
Qualifying criteria | All of the following:
| Poor asthma symptom control,¶ exacerbations requiring systemic glucocorticoids, or high risk of exacerbationΔ on step 1 therapy despite:
| Poor asthma symptom control,¶ exacerbations requiring systemic glucocorticoids, or high risk of exacerbationΔ on step 2 therapy despite:
| Poor asthma symptom control,¶ exacerbations requiring systemic glucocorticoids, or high risk of exacerbationΔ on step 3 therapy despite:
| Poor asthma symptom control,¶ exacerbations requiring systemic glucocorticoids, or high risk of exacerbationΔ on step 4 therapy despite:
| |
Option 1 | ICS-formoterol-based 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)§ | Medium-dose ICS-formoterol as maintenance and reliever therapy plus LAMA daily with Evaluation for biologic therapies* |
Option 2 | Alternative maintenance regimens | (No maintenance regimen) | (Anti-inflammatory reliever therapy without a maintenance regimen)״ 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 | Medium-dose ICS-LABA daily plus LAMA daily (or ICS-LAMA-LABA daily) or Medium-dose ICS-LABA daily plus LTRA daily with Evaluation for biologic therapies* |
and | 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◊¥ or ICS plus SABA as needed◊¥ 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 | ICS-SABA as needed◊ or ICS plus SABA as needed◊ or SABA, as needed |
This table illustrates simplified recommendations for stepping up asthma therapy. 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. Consultation with an asthma specialist is recommended if step 4 or higher is required.
Therapeutic strategies for newly diagnosed patients or for patients using SABA therapy alone are covered separately. Additional strategies for ongoing asthma treatment may be found in the accompanying graphic on guideline approaches to asthma controller therapy. Dosing information can be found in separate dosing tables for SABAs, 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.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; MDI: metered-dose inhaler; SABA: short-acting beta-agonist.
* Initiation of step 5 therapy should prompt assessment of asthma phenotype and evaluation for possible addition of asthma biologics. Asthma biologic therapies include anti-IgE, anti-IL-5, anti-IL-5R, anti-IL-4R (anti-IL-4/IL-13), and antithymic stromal lymphopoietin (anti-TSLP). Refer to UpToDate content on severe asthma and UpToDate graphic on our approach to selection of biologic agents for add-on therapy for severe asthma in adolescents and adults.
¶ Good asthma symptom control is generally defined as bothersome asthma symptoms or need for SABA inhaler less than twice a week, no nocturnal awakenings, and no activity limitations due to asthma. For patients on ICS-formoterol, ICS-SABA, or ICS plus SABA reliever therapy (aka, anti-inflammatory reliever therapy), reliever use more frequently (but less than daily) is reasonable as long as other symptoms are well-controlled.
Δ 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.
◊ When prescribed for use as-needed for acute asthma symptoms, ICS-formoterol, ICS-SABA, and concomitant ICS and SABA use are referred to as anti-inflammatory reliever therapy. Compared with SABA relievers, use of anti-inflammatory reliever therapy 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 anti-inflammatory reliever therapy 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 anti-inflammatory reliever therapy, but choice of therapy is also guided by patient preference, cost, and medication availability.
§ ICS-formoterol prescribed for use as both maintenance therapy and for acute relief of symptoms is referred to as maintenance and reliever therapy (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.
¥ For patients qualifying for step 2 therapy, only anti-inflammatory relievers (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?