National Asthma Education and Prevention Program (NAEPP)[1,2] | Global Initiative for Asthma (GINA)[3] | ||
Qualifying criteria | Therapy* | Qualifying criteria | Therapy |
Step 1 | Step 1 | ||
All of the following at initiation of therapy or using SABA alone:
|
| All of the following at initiation of therapy or using SABA alone:
|
|
Step 2 | Step 2 | ||
Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 1 therapy despite:
|
Alternative option(s)
| Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 1 therapy despite:
|
Other options
|
Step 3 | Step 3 | ||
Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 2 therapy despite:
|
Alternative option(s)
| Poor asthma control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 2 therapy despite:
|
Other options
|
Step 4 | Step 4 | ||
Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 3 therapy despite:
|
Alternative option(s)
| Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 3 therapy despite:
|
Other options
|
Step 5 | Step 5 | ||
Poor asthma control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 4 therapy despite:
|
and
| Poor asthma symptom control,* exacerbations requiring systemic glucocorticoids, or high risk of exacerbation¶ on Step 4 therapy despite:
|
and
Other options
|
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.
* 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.
¶ 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.
Δ 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.
◊ 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.
§ Theophylline and cromolyn are not included in the table even though they were included in NAEPP-EPR 3 (2007), and theophylline is included in NAEPP (2020). These agents are rarely used due to availability of more effective options.
¥ Asthma biologics include anti-immunoglobulin E, anti-IL-5, anti-IL-5R, anti-IL-4R (anti-IL-4/IL-13), and anti-thymic stromal lymphopoietin (anti TSLP). Refer to UpToDate graphic on our approach to selection of biologic agents for add-on therapy for severe asthma in adolescents and adults.Do you want to add Medilib to your home screen?