Treatment of Chronic Asthma

© The intensity ofpharmacotherapy for chronic asthma is based on disease severity for initial therapy and level of control for subsequent therapies. The least amount of medications necessary to meet the goals of asthma therapy should be used.1 Current recommendations for stepwise therapy for chronic asthma are shown in Figure 14-2. However, because of varying asthma presentations, the therapeutic plan must be individualized. The EPR-3 separates treatment recommendations into three categories based on patient age: (a) children younger than 5 years of age, (b) childrenbetween the ages of 5 and 11 years, and (c) individuals 12 years of age and older. Refer to Ref. 1 for more information on assessing asthma control and adjusting therapy in these three categories.1

Children 0-4 Years of Ago

Intermittent Asthma

Persistent Asthma: Daily Medication t


WooicliAMl Or LA8A


WooicliAMl Or LA8A

Step 5


High-dot« ICS

E«wr. Monirtjkast or LABA

Step 6


High-dote ICS ANO



Oral cortoosterods

Patient Education and Environmental Control at Each Slep

Siepi4>< needed

{»rtt. chack adherence and environmental controO

Assess control

S»p diwnil pouM

(and atthma a well controaed lor at least 3 month»)

Children 5-11 Years of Age

Intwmitlent Atthma

Persistent Atthma: Oarfy Mediation

Comut wdi astrrns speoatet rf step * care or h^>e* a r«**ed Cons«** corMMcn at s»p 3

Step 1 Preferred


Step 2 Preferred:

Low-dot« ICS Alternative:


Cromolyn. Nedocromi. or Theophy*ne

Step 3


Vedium-dose ICS

Low-dove CS ♦ WhorLABA. LTRA. or Theophyine

Step 4



Mediuovdot« ICS ♦ «"ther LTRA or Theophyttne



High-dote ICS


High-dove ICS

Step 6 Preferred:

Hgtvdose ICS


H^h-dose ICS

(Int. check adhcence and environmental control and comortud oondeoos)

Assess control

Patient Education and Environmental Control at Each Step

Sw 2-4: Consider SO .morgan imtxsiochQ'apy lor a'-j-g.; oa'<KiW

(Xxk-Rehet Medcaton lor Al Patents

• SABA as needed lor syirptoms intensity ol treatment deponds on soventy oi symptoms up io 3 treatments at 20-mmuee intervals at needed Short court« ol sytiemc oral oorticosierods may be needed

• Cauoon increat^g ute of beta-agon« or ute greater man 2 times a week lor symptom control (not proven ton oI ElB) indicates madequaie control and the need io «ep up treatment

Step down i postfcto

(and asthma a well contronod lor at least 3 months)

FIGURE 14-2. Stepwise approach for managing asthma in children (A) and adults (B).

(ICS, inhaled corticosteroids; LABA, long-acting P-agonists; LTRA, leukotriene receptor antagonist; PRN, as needed; SABA, short-acting P-agonist.) (From Ref. 20.)

8 Youths >12 Years of Age and Adults

Inlcrmillcnt Aithifiii

Step 1



Persistent Aithma. Daily Medication

Ojnf../i vrtlh ag-;nm3 SpeciBliS-i (I ilep 4 cam or Higher is required Consider (QnsuflBtiQn a1 step $

Step 2



Cromolyn, Medocfom LTRA, of Theophylline

Step 3


Medium-do sa ICS


Low-do» rCS ■ enher LTRA. Theophyiine orZiisuion

Step 4


Medium-dose ICS 4- Bilhar LTRA.

Theophylline or Zife-ulon

Step 5


Consider Omgllttiirmij tor patents vitio heve allergies

Step 6


High-Oose ICS t I ARA . Orel

çqdiWSferotd AND

Conider □mahzumab lor patients who hava allergies t

Step up it needed (Hirsl. check adherence, envKonmsfllel control, and comorbid condition»)

Assess control siapdownii yotsibld fend asthma is well tùnlratled tor ai IL>jsi 3 months)

Pitioni Education mid truiiionmoiilil CoiilroJ J»1 EtKh Stop

Siap 2-t Consider ÊÛ allerjen imniunoiiiarapy lor allergic oananis

Ûuflli-Re' çH Metfcalion igr All Pal^nls

■ SrtBAasneeflefl(or symptoms. Inwnsfly oi lreaimem dependsonseiifl-rity ol iymplorns; gpnl ifÉivnerit ai îo-rBifune irusivais ai needed Ston «ufia of system am MirieMteroids may 6a- needMi.

■ Use of jîj-agûflisi >2 dayi â wnîok ror symewm control (nsl pfewi-niion oi E IB) indicaiss jfiadsquflio wfllrotaiv) iha KI siip UÎ bwalmern.

Intermittent Asthma

Long-term control medications are not necessary in patients with intermittent asthma, and patients should use an SABA to prevent or treat symptoms.1 This classification includes patients with exercise-induced asthma, seasonal asthma, or asthma symptoms associated with infrequent trigger exposure. Patients can pretreat with two puffs of al-buterol, cromolyn, or nedocromil prior to exposure to a known trigger.

Persistent Asthma

Patients who use an SABA more than twice a week for symptom control (not exercise-induced bronchospasm) should be treated as persistent asthma. Patients who experienced two or more exacerbations requiring oral corticosteroids in the past year may also be categorized as having persistent asthma.1 Patients with persistent asthma require daily long-term control therapy (see Tables 14-2 and 14-3). However, daily therapy limited to a predefined period of risk (e.g., seasonal asthma) may be considered when these periods are identified by history. ICS are the long-term control medication of choice at all levels of severity and in all age groups.1 SABAs should be prescribed for all patients with chronic asthma for use on an as-needed basis.

After initiating therapy, patients should be monitored within 2 to 6 weeks to ensure that asthma control has been achieved. Before increasing therapy, the patient's inhaler technique and adherence to therapy should be evaluated.1 Patients with controlled asthma should be monitored at 1-to 6-month intervals to ensure control is maintained. A gradual stepdown in control therapy should be initiated when possible, usually once control has been maintained for at least 3 months.1

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