Table 1:
Stepwise Approach for Managing Asthma in Adults and Children Older Than 5 Years of Age: Treatment
Classify Severity:
Clinical Features Before Treatment or Adequate Control
Medications Required to Maintain Long-Term Control
  
Symptoms/Day
Symptoms/Night
PEF or FEV1
PEF Variability
Daily Medications
Step 4

Severe Persistent
Continual
Frequent
< 60%
> 30%
Preferred Treatment
—High-dose inhaled corticosteroids
AND
—Long-Acting beta2-agonists
AND, if needed,
—Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)
Step 3

Moderate Persistent
Daily
> 1 night/week
> 60% - <80%
> 30%
Preferred Treatment
—Low-to-medium dose inhaled corticosteroids and long-acting beta2-agonists.
Alternative Treatment
—Increase inhaled corticosteroids within medium-dose range
OR
—Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophylline.

If needed (particularly in patients with recurring severe exacerbations):
Preferred Treatment
—Increase inhaled corticosteroids within medium-dose range and
add long-acting beta2-agonists.
Alternative Treatment
—Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
Step 2

Mild Persistent
> 2/week but < 1x/day
> 2 nights/month
> 80%
20 - 30%

Preferred Treatment
—Low-dose inhaled corticosteroids
Alternative Treatment
(listed alphabetically): cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentration of 5-15 µg/mL.
Step 1

Mild Intermittent
< 2 days/week
< 2 nights/month
> 80%
< 20%
 No daily medication needed.

Severe exacerbations may occur, separated by long periods of normal long function and no symptoms. A course of systemic corticosteroids is recommended.
  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quick Relief

All Patients
  • Short-acting bronchodilator: 2-4 puffs short-acting beta2-agonists as needed for symptoms.
  • Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20-minute intervals or a single nebulizer treatment as needed. Course of systemic corticosteroids may be needed.
  • Use of short-acting beta2-agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy.

 

 

 

 

 

 

Step down
Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible.

Step up
If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control.

 

Note

  • The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs.
  • Classify severity: assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV1 is % predicted).
  • Gain control as quickly as possible (consider a short course of systemic corticosteroids); then step down to the least medication necessary to maintain control.
  • Provide education on self-management and controlling environmental factors that make asthma worse (eg, allergens and irritants).
  • Refer to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if step 3 care is required.

 

 

 

 

 

Goals of Therapy: Asthma Control
  • Minimal or no chronic symptoms day or night
  • Minimal or no exacerbations
  • No limitations on activities; no school/work missed

 
  • Maintain (near) normal pulmonary function
  • Minimal use of short-acting inhaled beta2-agonist (< 1x per day, < 1 canister/month
  • Minimal or no adverse effects from medication

 

 

 

 

 

 

 

 

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