asthma

1. ASTHMA MANAGEMENT

2. STEPWISE APPROACH TO TREATING ASTHMA
The National Asthma Education and Prevention Program recommends a
stepped approach to asthma treatment based on age and asthma
severity.
Where you begin on the steps depends on how intense your asthma is
at first. If you follows other guidelines, your treatment may be different.
Ultimate goal should be to have a good control of asthmatic attacks.

3. STEPWISE APPROACH TO TREATING ASTHMA
If 1 drug is not enough to control your asthma in 2 to 6 weeks, your
treatment goes up 1 step. This may mean increasing the dose or adding
another drug.
If your asthma is well controlled for at least 3 months, you may go down
1 step. Going down a step means will try a lower dose or cutting out a
drug to see if your asthma stays under control.

4. STEPWISE APPROACH TO TREATING ASTHMA
• In general, the types of asthma control medicines prescribed for the 6 steps of asthma severity
include:
 Inhaled steroids
 Short-acting beta agonists (SABAs)
 Long-acting beta agonists (LABAs)
 Long-acting muscarinic antagonists (LAMAs)
 Leukotriene receptor antagonists (LTRAs)
 Theophylline
 Asthma biologics
• Immunotherapy
The recommendations for when these drugs are prescribed change based on a person’s age and
asthma severity

5. STEPWISE
APPROACH
TO ASTHMA
MANAGEMENT
FOR CHILDREN AGES
0 TO 4 YEARS
Every step: Reduce exposure to triggers, exercise,
eat healthy, and manage stress
Steps 2, 3, and 4: Consider immunotherapy for
allergies
Steps 5 and 6: Consider adding asthma biologic
ICS=inhaled corticosteroids, LABA=long-acting
beta agonists, LAMA=Long-acting muscarinic
antagonists, LTRA=Leukotriene receptor
antagonists, SABA=short-acting beta agonists
Step
1
 Short course of ICS (daily) and SABA (as needed)
Step
2
 Low-dose ICS (daily) and SABA (as needed)
 Alternative: LTRA (daily) and SABA (as needed)
Consult an asthma specialist before Step 3
Step
3
 Low-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: low-dose ICS and LTRA (daily) and SABA (as needed)
 Alternative: medium-dose ICS (daily)
Step
4
 Medium-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: medium-dose ICS and LTRA (daily) and SABA (as needed)
Step
5
 High-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: high-dose ICS and LTRA (daily) and SABA (as needed)
Step
6
 High-dose ICS-LABA and oral corticosteroid (daily) and SABA (as needed)
 Alternative: High-dose ICS and LTRA and oral corticosteroid (daily) and SABA
(as needed)

6. STEPWISE
APPROACH
TO ASTHMA
MANAGEMENT
FOR CHILDREN AGES
5 TO 11 YEARS
Every step: Reduce exposure to triggers, exercise,
eat healthy, and manage stress
Steps 2, 3, and 4: Consider immunotherapy for
allergies
Steps 5 and 6: Consider adding asthma biologics
ICS=inhaled corticosteroids, LABA=long-acting
beta agonists, LAMA=Long-acting muscarinic
antagonists, LTRA=Leukotriene receptor
antagonists, SABA=short-acting beta agonists
Step 1  SABA with low-dose ICS (as needed)
 Alternative: low-dose ICS (daily) and SABA (as needed)
Step 2  Low-dose ICS (daily) and SABA (as needed)
 Alternative: LTRA (daily) and SABA (as needed)
 Consider: Add allergy shots
Step 3  Low-dose ICS-formoterol (daily and as needed)
 Alternative: medium-dose ICS (daily) and SABA (as needed)
 Alternative: low-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: low-dose ICS and LTRA/LAMA (daily) and SABA (as needed)
 Consider: Add allergy shots
Consult an asthma specialist before Step 4
Step 4  Low-/medium-dose ICS-formoterol (daily and as needed)
 Alternative: medium-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: medium-dose ICS and LTRA/LAMA (daily) and SABA (as needed)
 Consider: Add allergy shots
Step 5  High-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: high-dose ICS and LTRA/LAMA (daily) and SABA (as needed)
 Consider: Add omalizumab or dupilumab
 Consider: Add other biologics or oral corticosteroids

7. STEPWISE
APPROACH
TO ASTHMA
MANAGEMENT
FOR ANYONE 12
YEARS OR OLDER
Every step: Reduce exposure to triggers, exercise,
eat healthy, and manage stress
Steps 2, 3, and 4: Consider immunotherapy for
allergies
Steps 5 and 6: Consider adding asthma biologics
ICS=inhaled corticosteroids, LABA=long-acting
beta agonists, LAMA=Long-acting muscarinic
antagonists, LTRA=Leukotriene receptor
antagonists, SABA=short-acting beta agonists
Step
1
 Low-dose ICS-formoterol (as needed)
 Alternative: SABA with ICS (as needed)
Step
2
 Low-dose ICS-formoterol (as needed)
 Alternative: SABA with ICS (as needed)
 Alternative: low-dose ICS (daily) and SABA (as needed)
 Alternative: LTRA (daily) and SABA (as needed)
 Consider: Add allergy shots
Step
3
 Low-dose ICS-formoterol (daily and as needed)
 Alternative: low-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: medium-dose ICS (daily) and SABA (as needed)
 Alternative: low-dose ICS and LTRA/LAMA (daily) and SABA (as needed)
 Consider: Add allergy shots
Consult an asthma specialist before Step 4
Step
4
 Medium-dose ICS-formoterol (daily and as needed)
 Alternative: medium-/high-dose ICS-LABA (daily) and SABA (as needed)
 Alternative: medium-dose ICS and LTRA/LAMA (daily) and SABA (as needed)
 Consider: Add allergy shots
Step
5
 Medium-dose ICS-formoterol (daily and as needed) and LAMA (daily)
 Alternative: medium-/high-dose ICS-LABA and LAMA (daily) and SABA (as
needed)
 Consider: Add biologics, azithromycin, or low-dose oral corticosteroids

8. INHALED STEROIDS
• Inhaled steroids (inhalers) are the backbone of asthma treatment for most
adults and children with long-term asthma. Inhaled steroids make the airways
less inflamed and less sensitive. This leads to less severe asthma symptoms
and better lung function. You are less likely to have an asthma attack or need
to visit the emergency room if you take inhaled corticosteroids.
• There are many types of inhaled steroids available, such as:
 Ciclesonide
 Budesonide
• Different inhaled steroids may be given at different stages of asthma severity.

9. LONG-ACTING BETA AGONISTS
• Long-acting beta agonists (LABAs) relax the muscles that surround the airways. LABAs
are used together with inhaled corticosteroids to treat people with moderate to severe
asthma. LABAs reduce asthma symptoms, asthma attacks, and rescue medication use.
• LABAs are packaged alone or in combination inhalers with a corticosteroid. Combination
inhalers include an inhaled steroid and a LABA in 1 device. Some common brands include:
 Fluticasone propionate/salmeterol
 Mometasone/formoterol fumarate
 Budesonide/formoterol fumarate
 Fluticasone furoate/vilanterol
• You may ask to stop taking a LABA for a period of time to see if your patient’s asthma
stays controlled without it.

10. LEUKOTRIENE MODIFIERS
• Leukotriene receptor antagonists (LTRAs) block leukotrienes. Leukotrienes are chemicals
the body releases after being exposed to an allergy trigger. LTRAs may also be called
leukotriene modifiers. These are pills taken by mouth.
• LTRAs can be used instead of inhaled steroids for people with mild to moderate asthma
(Step 2). Leukotriene modifiers can also be used in addition to inhaled corticosteroids for
moderate asthma (Steps 3 and 4). This group of drugs does not work as well as inhaled
steroids to control and prevent asthma but can be useful to some people.
• There are many brands of LTRAs. Some include:
 Montelukast
 Zafirlukast)
 Zileuton

11. ORAL STEROIDS
Oral corticosteroids reduce inflammation. These drugs may be used
short-term at the start of an asthma attack or after an attack.
Common oral steroids include methylprednisolone, prednisolone,
and prednisone.

12. BIOLOGICS
• Biologics are drugs that target a specific molecule, cell, or antibody that is causing a person’s
asthma. Biologics are given by an injection under the skin or as an infusion into a vein.
• Biologics are used for moderate to severe asthma that is not well controlled by other drugs. This
includes people who are regularly admitted to the hospital, use a rescue inhaler several times a day or
week, or who are taking oral steroids.
• There are several biologics for asthma, including:
 Xolair (omalizumab)
 Nucala (mepolizumab)
 Cinqair (reslizumab)
 Fasenra (benralizumab)
 Dupixent (dupilumab)