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GUIDELINES FOR THE PHARMACOLOGICAL MANAGEMENT

OF ASTHMA
Consultas de fármacos

PATIENT DATA/BACKGROUND

The pharmacologic approach to treating asthma is separated into steps. Treatment is dictated by
the severity of symptoms with the intent of suppressing airway inflammation and should be
initiated at a higher level than the patient's current step of severity to establish prompt control of
symptoms. Once exacerbation symptoms are controlled, step down therapy is essential to
determine the minimum medication necessary to maintain goals for therapy [1].

◾ The goals of therapy are to:

◾ Reduce impairment:
◾ prevent chronic and troublesome symptoms
◾ for quick relief of symptoms, require 2 or less days/week of inhaled SABAs
◾ maintain normal activities, including exercise
◾ maintain normal or near normal lung function
◾ meet patients' and families' expectations of and satisfaction with asthma care
◾
◾ Reduce risk:
◾ prevent recurrent exacerbations and minimize need for emergency care or
hospitalization
◾ prevent progressive loss of lung function
◾ for children, prevent reduced lung growth
◾ minimize drug-related adverse effects

RESPONSE

The first step is to classify the patient's asthma severity.

◾ CLASSIFICATION OF ASTHMA SEVERITY IN PATIENTS NOT CURRENTLY TAKING

LONG-TERM CONTROL MEDICATION
◾ SEVERE PERSISTENT:
◾ ADULTS AND CHILDREN (12 YEARS AND OLDER)
◾ Symptoms are continual with 2 or more exacerbations/year requiring oral
corticosteroids, and extreme limitations on normal activity. Nighttime symptoms are
often 7 times/week and short-acting beta-agonist (SABA) use is several times/day for
symptom control.
◾ FEV1 less than 60% predicted
◾ FEV1/FVC greater than 5% reduction
◾ CHILDREN (5 to 11 YEARS OF AGE)
◾ Symptoms are continual with 2 or more exacerbations/year requiring oral
corticosteroids, and extreme limitations on normal activity. Nighttime symptoms are
often 7 times/week and SABAs use is several times/day for symptom control.
◾ FEV1 less than 60% predicted

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◾ FEV1/FVC less than 75%

◾ CHILDREN (0 to 4 YEARS OF AGE)
◾ Symptoms are continual with two or more exacerbations/6 months requiring oral
corticosteroids, or 4 or more wheezing episodes/1 year lasting greater than 1 day AND
risk factors for persistent asthma. There are extreme limitations on normal activity and
nighttime symptoms are more than 1 time/week. SABA use is several times/day for
symptom control.
◾ MODERATE PERSISTENT:
◾ ADULTS AND CHILDREN (12 YEARS AND OLDER)
◾ Symptoms occur daily with 2 or more exacerbations/year requiring oral corticosteroids,
and some limitation on normal activity. Nighttime symptoms occur more than once per
week, but not nightly, and SABA use is daily for symptom control.
◾ FEV1 greater than 60% but less than 80% predicted
◾ FEV1/FVC 5% reduction
◾ CHILDREN (5 TO 11 YEARS OF AGE)
◾ Symptoms occur daily with 2 or more exacerbations/year requiring oral corticosteroids,
and some limitation on normal activity. Nighttime symptoms occur more than once per
week, but not nightly, and SABA use is daily for symptom control.
◾ FEV1 between 60% and 80% predicted
◾ FEV1/FVC between 75% and 80%
◾ CHILDREN (0 to 4 YEARS OF AGE)
◾ Symptoms occur daily with two or more exacerbations/6 months requiring oral
corticosteroids, or 4 or more wheezing episodes/1 year lasting greater than 1 day AND
risk factors for persistent asthma. There is some limitation on normal activity, and
nighttime symptoms are 3 to 4 times/month. SABA use is daily for symptom control.
◾ MILD PERSISTENT:
◾ ADULTS AND CHILDREN (12 YEARS AND OLDER)
◾ Symptoms occur more than 2 times weekly but not daily with two or more
exacerbations/year requiring oral corticosteroids, and minor limitation on normal
activity. Night-time symptoms occur 3 to 4 times/month. SABA use is more than 2
days/week but not more than 1 time/day.
◾ FEV1 at least 80% predicted
◾ FEV1/FVC normal
◾ CHILDREN (5 TO 11 YEARS OF AGE)
◾ Symptoms occur more than 2 times weekly but not daily with two or more
exacerbations/year requiring oral corticosteroids, and minor limitation on normal
activity. Night-time symptoms occur 3 to 4 times/month. SABA use is more than 2
days/week but not more than 1 time/day.
◾ FEV1 at least 80% predicted
◾ FEV1/FVC greater than 80%
◾ CHILDREN (0 to 4 YEARS OF AGE)
◾ Symptoms are greater than 2 days/week, but not daily with two or more
exacerbations/6 months requiring oral corticosteroids, or 4 or more wheezing
episodes/1 year lasting greater than 1 day AND risk factors for persistent asthma.
There is minor limitation on normal activity, and nighttime symptoms are 1 to 2
times/month. SABA use is greater than 2 days/week but not daily for symptom control.

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◾ INTERMITTENT:
◾ ADULTS AND CHILDREN (12 YEARS AND OLDER)
◾ Symptoms occur no more than 2 times a week with 0 to 1 exacerbations/year requiring
oral corticosteroids, and patients are asymptomatic. Nighttime symptoms occur no
more than 2 times monthly. SABAs use is 2 days or less per week.
◾ FEV1 normal between exacerbations
◾ FEV1, greater than 80% predicted
◾ FEV1/FVC normal
◾ CHILDREN (5 TO 11 YEARS OF AGE)
◾ Symptoms occur no more than 2 times a week with 0 to 1 exacerbations/year requiring
oral corticosteroids, and patients are asymptomatic. Nighttime symptoms occur no
more than 2 times monthly. SABAs use is 2 days or less per week.
◾ FEV1 normal between exacerbations
◾ FEV1 greater than 80% predicted
◾ FEV1/FVC greater than 85%
◾ CHILDREN (0 to 4 YEARS OF AGE)
◾ Symptoms occur no more than 2 days/week with 0 to 1 exacerbations/year requiring
oral corticosteroids and no interference in normal activity. There are no nighttime
symptoms, and SABA use is 2 days or less per week for symptom control.

◾ Definitions:
◾ FEV1, forced expiratory volume in 1 second
◾ FEV1/FVC, forced expiratory volume in 1 second/forced vital capacity

The next step is to establish prompt control of asthma symptoms. The following guidelines
reflect consensus recommendations based upon systematic review of the literature and are
supported by the National Institute of Health (NIH) and National, Heart, Lung, Blood Institute
(NHLBI) . Treatment should be initiated after classifying individual asthma severity and with
intention of gaining control as quickly as possible, followed by stepping down the least
medication necessary to maintain control [1].

Patients with asthma should be managed in a stepwise approach. Prior to stepping up

treatment, an assessment of adherence, inhaler technique, environmental control, and comorbid
conditions should be performed. Once asthma has been well controlled for at least 3 months, a
step down, if possible, should be attempted [1].

Stepwise Approach for Managing Asthma

Step Population Preferred Alternative

Adult and
youth (12 yo SABA as needed none
Step and older)
1 Child 5 to 11
SABA as needed none
yo
Child 0 to 4 yo SABA as needed none
cromolyn, LTRA,
Adult Low dose ICS nedocromil, or
theophylline
Step
cromolyn, LTRA,
2 Child 5 to 11
Low dose ICS nedocromil, or
yo
theophylline
Child 0 to 4 yo Low dose ICS cromolyn or montelukast

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Adult and Low dose ICS + LABAorMedium dose ICSLow dose ICS + either
youth (12 yo LTRA, theophylline, or
Step and older) zileuton
3 Child 5 to 11 Low dose ICS + either LABA, LTRA, or
none
yo theophyllineorMedium dose ICS
Child 0 to 4 yo Medium dose ICS none
Adult and Medium dose ICS +
youth (12 yo Medium dose ICS + LABA either LTRA,
and older) theophylline, or zileuton
Step Medium dose ICS +
Child 5 to 11
4* Medium dose ICS + LABA either LTRA or
yo
theophylline
Medium dose ICS + either LABA or
Child 0 to 4 yo none
montelukast
Adult and High dose ICS + LABA andConsider
youth (12 yo omalizumab for patients who have none
and older) allergies
Step
Child 5 to 11 High dose ICS + either
5* High dose ICS + LABA
yo LTRA or theophylline
High dose ICS + either LABA or
Child 0 to 4 yo none
montelukast
Adult and High dose ICS + LABA + oral
youth (12 yo corticosteroidsandConsider omalizumab none
and older) for patients who have allergies
Step High dose ICS + either
Child 5 to 11 High dose ICS + LABA + oral
6* LTRA or theophylline +
yo corticosteroids
oral corticosteroids
High dose ICS + either LABA or
Child 0 to 4 yo none
montelukast + oral corticosteroids
KEY: yo= years old; SABA = short-acting beta2-agonist; ICS = inhaled corticosteroids;
LTRA = leukotriene receptor antagonist; LABA = long-acting beta2-agonists; * = consult
with an asthma specialist, when step 4 care or higher is required in adults and youth and
when step 3 care or higher is required in children 0 to 4 yo; furthermore, consider
consultation at step 3 in adults and youth and at step 2 in children 0 to 4 yo

◾ Rescue Medications
◾ Rescue medications (short-acting beta2-agonist (SABA) and when needed, short courses
of oral corticosteroids) may be needed for adults and children. Adults and children 5 years
and older may be treated with SABA up to 3 treatments at 20-minute intervals. The
intensity of treatment in children 0 to 4 years of age depends on severity of symptoms. But
when viral respiratory infection is present, treatment with SABA every 4 to 6 hours up to 24
hours or longer may be necessary. Short courses of oral corticosteroids can be considered
when exacerbations are severe or the child has a history of severe exacerbations [1].

Therapy should be reviewed every 1 to 6 months, to achieve the lowest possible doses while
maintaining normal activities. Stepping up is recommended when:

◾ Symptoms or nighttime awakenings increase

◾ Reduced ability to play, exercise, or participate in normal daily activities
◾ Short-acting beta2-agonists use increases
◾ Lung function, FEV1, PEF, or FEV1/FVC is reduced
◾ Increase frequency of exacerbations requiring oral corticosteroids
◾ Intolerable drug-related adverse effects
◾ Reduction in lung growth in children 5 to 11 years
◾ Validated questionnaires to measure asthma control in adults and children 12 years and older
demonstrate reduced control

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◾ Progressive loss of lung function in adults and children 12 years and older

◾ Immunotherapy
◾ Subcutaneous allergen immunotherapy may be considered in adults and children older
than 5 years with allergic asthma [1].

Inhaled Corticosteroids

◾ The use of inhaled corticosteroids (ICS) is the mainstay of asthma pharmacotherapy. The
lowest effective dose should be used. Usual doses of these agents are listed below [1].

Adults Children
Daily
Drug Formulation
Dose 12 years 5 to 11 yo 0 to 4 yo
and older
80 to 240 80 to 160
HFA L NA
mcg mcg
greater than greater
Beclomethasone40 to 80 HFA M 240 to 480 than 160 to NA
mcg/puff mcg 320 mcg
greater
greater than
HFA H than 320 NA
480
mcg
180 to 600 180 to 400
DPI L NA
mcg mcg
greater than greater
Budesonide90, 180, 200 DPI M 600 to 1200 than 400 to NA
mcg/inhalation mcg 800 mcg
greater
greater than
DPI H than 800 NA
12000 mcg
mcg
0.25 to 0.5
Nebs L NA 0.5 mg
mg
Budesonide 0.25 mg/2 mL, greater
0.5 mg/2 mL, 1 mg/2 mL Nebs M NA 1 mg than 0.5 to
suspension 1 mg
greater
Nebs H NA 2 mg
than 1 mg
500 to 1000 500 to 750
CFC L NA
mcg mcg
greater than
1000 to
CFC M 1000 to NA
Flunisolide 250 mcg/puff 1250 mcg
2000 mcg
greater
greater than
CFC H than 1250 NA
2000 mcg
mcg
HFA L 320 mcg 160 mcg NA
greater than
HFA M 320 to 640 320 mcg NA
Flunisolide 80 mcg/puff
mcg
greater than 640 mcg or
HFA H NA
640 mcg greater
Fluticasone 44, 110, or 220 88 to 264 88 to 176
HFA L 176 mcg
mcg/puff mcg mcg
greater than greater greater
HFA M 264 to 440 than 176 to than 176 to
mcg 352 mcg 352 mcg

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HFA H greater than greater greater

440 mcg than 352 than 352
mcg mcg
100 to 300 100 to 200
DPI L NA
mcg mcg
greater than greater
Fluticasone 50, 100, or 250 DPI M 300 to 500 than 200 to NA
mcg/inhalation mcg 400 mcg
greater
greater than
DPI H than 400 NA
500 mcg
mcg
DPI L 200 mcg NA NA
Mometasone 200 DPI M 400 mcg NA NA
mcg/inhalation greater than
DPI H NA NA
400 mcg
300 to 750 300 to 600
DPI L NA
mcg mcg
greater than greater
Triamcinolone acetonide 75 DPI M 750 to 1500 than 600 to NA
mcg/puff mcg 900 mcg
greater
greater than
DPI H than 900 NA
1500 mcg
mcg
KEY: yo = years old; HFA = hydrofluoroalkane; CFC = chlorofluorocarbon; DPI = dry
powder inhalation; Nebs = inhalation suspension for nebulization; L = low; M = medium;
H = high; mcg = micrograms; mg = milligrams; NA = not applicable (either no data or not
approved)

Drugs used to treat asthma are classified as long-term control medications (eg, ICS, LTRA,
LABA, methylxanthines, mast cell stabilizers), which are used daily to prevent asthma attacks, or
quick relief medications (eg, short-acting inhaled beta-2 agonist or inhaled anticholinergic
agents), which are used when an asthma attack is occurring. This terminology helps the patient
better understand when to use what medication [1].

◾ LONG-TERM CONTROL MEDICATIONS:

◾ Mast cell stabilizers
◾ cromolyn
◾ nedocromil
◾ Immunomodulators (12 years and older)
◾ omalizumab
◾ Inhaled corticosteroids (ICS):
◾ beclomethasone
◾ budesonide
◾ flunisolide
◾ fluticasone
◾ mometasone
◾ triamcinolone
◾ Leukotriene receptor antagonist (LTRA):
◾ montelukast
◾ zafirlukast
◾ 5-lipoxygenase inhibitor

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◾ zileuton
◾ Long-acting inhaled beta-2 agonists (LABA)
◾ formoterol
◾ salmeterol
◾ Methylxanthines
◾ theophylline, sustained release

◾ QUICK RELIEF MEDICATIONS:

◾ Anticholinergic inhaled agents
◾ ipratropium
◾ Corticosteroids, oral
◾ methylprednisolone
◾ prednisolone
◾ prednisone
◾ Short-acting inhaled beta-2 agonists
◾ albuterol
◾ bitolterol
◾ levalbuterol
◾ pirbuterol

Routine use of anticholinergic agents for treatment of asthma is not supported. Inhaled
anticholinergics may offer some additive benefit to inhaled beta-2 agonists in moderate to severe
acute asthma exacerbations [1].

CONCLUSION

Persistent asthma symptoms, managed with pharmacological therapy, is intended to achieve

rapid and long-term control while minimizing adverse drug-related effects and impact on the
patient's quality of life and daily activities. This is accomplished through stepwise approach for
managing asthma.

Reference
1. National Heart,Lung,and Blood Institute: Expert panel report 3: guidelines for the diagnosis and
management of asthma. National Heart,Lung,and Blood Institute. Bethesda, MD. 2007. Available
from URL: http://www.nhlbi.... .

Last Modified: November 20, 2009

© 2014 Truven Health Analytics Inc.

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