Table 3 : Stepwise approach for managing asthma in patients ages 12 and older .
INTERMITTENT ASTHMA
PERSISTENT ASTHMA ( Daily Medication )
Consult with asthma specialist if Step 4 care or higher is required . Consider consultation at Step 3 .
Step 1 Preferred : Low-dose ICS
Preferred : SABA prn
Alternative : Cromolyn , LTRA , nedocromil or theophylline
Step 2 Preferred : Either Low-dose ICS
Step 4 Preferred : High-dose ICS + LABA
Step 3 Preferred : Medium-dose ICS + LABA
+ LABA or medium-dose ICS
Alternative : Low-dose ICS + either LTRA , theophylline , or zileuton
Alternative : Medium-dose ICS + either LTRA or theophylline
Step 6
Step 5 Preferred :
Alternative : High-dose ICS + either LTRA or theophylline
Consider : Omalizumab for patients who have allergies
High-dose ICS + LABA + oral systemic corticosteroid
Alternative : High-dose ICS + either LTRA or theophylline + oral systemic corticosteroid
Consider : Omalizumab for patients who have allergies
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 )
� EIB = exercise-induced bronchospasm
� 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 .
� Zileuton is a less desirable alternative drug due to limited studies as adjunctive therapy and the need to monitor liver function . Theophylline requires monitoring of serum concentration levels .
� In Step 6 , before oral systemic corticosteroids are introduced , a trial of high-dose ICS + LABA + either ( LTRA , theophylline ) or zileuton may be considered , although this approach has not been studied in clinical trials .
� Steps 1 through 3 preferred therapies are based on Evidence A ; Step 3 alternative therapy is based on Evidence A for LTRA , Evidence B for theophylline , and Evidence D for zileuton . Step 4 preferred therapy is based on Evidence B and alternative therapy is based on Evidence B for LTRA and theophylline and Evidence D for zileuton . Step 5 preferred therapy is based on Evidence B . Step 6 preferred therapy is based on ( EPR-2 1997 ) and Evidence B of omalizumab .
� 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 .
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