Mount Carmel Health Partners Clinical Guidelines Asthma | Page 7

Table 2: Stepwise approach for managing asthma in children ages 5 to 11 INTERMITTENT ASTHMA PERSISTENT ASTHMA (Daily Medication) Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Step 6 Step 5 Step 4 Step 3 Step 2 Preferred: Low-dose ICS Step 1 Preferred: SABA prn Alternative: cromolyn, LTRA, nedocromil or theophylline Preferred: Either low-dose ICS + (either LABA, LTRA or theophylline) or medium-dose ICS Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA or theophylline Preferred: High-dose ICS + LABA Alternative: High-dose ICS + either LTRA or theophylline Preferred: High-dose ICS + LABA + oral systemic corticosteroid Alternative: High-dose ICS + either LTRA or theophylline + oral systemic corticosteroid Assess control: check adherence, inhaler technique, environmental control, and comorbid conditions. Step up if needed and step down if possible (if well-controlled at least three months). Each Step: Patient/parent education, environmental control, and management of comorbidities. Steps 2 through 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes). KEY (alphabetical order)  ICS = inhaled corticosteroid  LABA = inhaled long-acting beta 2 -agonist  LTRA = leukotriene receptor agonist  SABA = inhaled short-acting beta 2 -agonist QUICK RELIEF MEDICATION (all patients)  SABA as needed for symptoms; intensity of treatment depends on severity of symptoms; up to three treatments at 20-minute intervals as needed.  Use of SABA more than two days a week for symptom relief–not prevention of EIB–generally indicates inadequate control and the need to step up treatment. NOTES  This approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs.  If an alternative treatment is used and the response is inadequate, discontinue it and use the preferred treatment before stepping up.  Theophylline is a less desirable alternative due to the need to monitor serum concentration levels.  Step 1 and Step 2 medications are based on Evidence A. Step 3 ICS + adjunctive therapy and ICS are based on Evidence B for efficacy of each treatment and extrapolation from comparator trials in older children and adults (comparator trials are not available for this age group); Steps 4 through 6 are based on expert opinion and extrapolation from studies in older children and adults.  Immunotherapy for Steps 2 through 4 is based on Evidence B for house-dust mites, animal dander and pollens; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify and treat anaphylaxis should it occur. Source: Adapted from the National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Full Report 2007. Asthma - 7