Asthma in adults

• Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

Primary Options

• These therapies are considered potential second-line alternatives to inhaled corticosteroids (ICS).

• Sodium cromoglicate and nedocromil have some, but limited, effectiveness, and a strong safety profile. A 4- to 6-week trial may be needed to determine maximal benefit; once control is achieved, dose may be reduced

• LTRAs, such as montelukast and zafirlukast, provide long-term control, prevent symptoms, and are alternative, but not preferred, therapies for patients who have mild persistent asthma, because studies comparing overall efficacy of ICS and LTRAs favour ICS on most asthma outcome measures.[B Evidence] They should not be used for acute attacks or as monotherapy for exercise-induced bronchospasm. [56] [57]

• Sustained-release theophylline is an alternative, but not preferred, long-term control medication. It is not preferred because the modest clinical effectiveness (theophylline is primarily a bronchodilator and its anti-inflammatory activity demonstrated thus far is modest) must be balanced against concerns about potential toxicity. [58] Theophylline remains a therapeutic option for certain patients due to expense or need for tablet-form medication. Serum monitoring important due to wide inter-patient variation. Sustained-release theophylline is given to achieve a serum concentration of between 5 and 15 microgram/mL at steady state. Periodic theophylline monitoring is necessary to maintain a therapeutic, but not toxic, level.

Primary Options

• Step 3 therapy adds an LABA. [48] [49] [B Evidence][B Evidence]

Primary Options

• Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

Primary Options

• Moderate persistent is defined as: daily symptoms; use of short-acting beta agonists daily; attacks affect activity; exacerbations ≥2 times a week and may last for days; night-time symptoms >1 time a week; FEV1 >60% to <80% of predicted peak expiratory flow rate (PEFR) variability >30%.

• Step 3 therapy may involve increasing the dose of the ICS to a medium-dose range rather than add a long-acting beta-agonist (LABA).[B Evidence]

• ICS are given in divided doses, generally using a spacer/holding chamber device if using a metered-dose inhaler. [55]

Primary Options

• Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

Primary Options

• Second-line alternative is to combine a low-dose ICS with either an LTRA, [47] [B Evidence] theophylline,[C Evidence] or zileuton.

• Sustained-release theophylline is an alternative, but not preferred, long-term control medication. It is not preferred because the modest clinical effectiveness (theophylline is primarily a bronchodilator and its anti-inflammatory activity demonstrated thus far is modest) must be balanced against concerns about potential toxicity. [58] Theophylline remains a therapeutic option for certain patients due to expense or need for tablet-form medication. Serum monitoring important due to wide inter-patient variation. Sustained-release theophylline is given to achieve a serum concentration of between 5 and 15 micrograms/mL. Periodic theophylline monitoring is necessary to maintain a therapeutic, but not toxic, level. [59]

• ICS are given in divided doses, generally using a spacer/holding chamber device if using a metered-dose inhaler. [55]

Primary Options

• Preferred treatment is to add an LABA to a medium-dose inhaled corticosteroid (ICS).[B Evidence][B Evidence]

• Addition of tiotropium to an ICS has been shown to improve symptoms and lung function in patients with inadequately controlled asthma. Its effects appear to be equivalent to those seen with the addition of salmeterol. [50] [B Evidence]

Primary Options

• Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

Primary Options

• Second-line alternative is to combine a medium-dose ICS with either an LTRA, [47] [B Evidence] theophylline,[C Evidence] or zileuton.

• ICS are given in divided doses, generally using a spacer/holding chamber device if using a metered-dose inhaler. [55]

• Sustained-release theophylline is an alternative, but not preferred, long-term control medication. It is not preferred because the modest clinical effectiveness (theophylline is primarily a bronchodilator and its anti-inflammatory activity demonstrated thus far is modest) must be balanced against concerns about potential toxicity. [58] Theophylline remains a therapeutic option for certain patients due to expense or need for tablet-form medication. Serum monitoring important due to wide inter-patient variation. Sustained-release theophylline is given to achieve a serum concentration of between 5 and 15 micrograms/mL. Periodic theophylline monitoring is necessary to maintain a therapeutic, but not toxic, level.

Primary Options

• Preferred treatment is to add an LABA to a high-dose ICS.[B Evidence][B Evidence]

• Addition of tiotropium to an ICS has been shown to improve symptoms and lung function in patients with inadequately controlled asthma. Its effects appear to be equivalent to those seen with the addition of salmeterol. [50] [B Evidence]

Primary Options

• Consider for patients with known allergy. [51] [52] [53]

Primary Options

• ICS are given in divided doses, generally using a spacer/holding chamber device if using a metered-dose inhaler. [55]

• Fluticasone is reported to suppress the pituitary-adrenal access at high doses (800 micrograms/day) in single case reports. [60] [61]

Primary Options

• Preferred treatment is to add an LABA to a high-dose inhaled corticosteroid (ICS) and oral corticosteroid.[B Evidence][B Evidence]

• Addition of tiotropium to an ICS has been shown to improve symptoms and lung function in patients with inadequately controlled asthma. Its effects appear to be equivalent to those seen with the addition of salmeterol. [50] [B Evidence]

Primary Options

• Consider for patients with known allergy. [51] [52] [53]

Primary Options

• Increasing use of a SABA or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

Primary Options

• For well-controlled confirmed allergic asthma, treatment with allergen immunotherapy is an option.

• This treatment is only used with documented allergies either by skin testing or specific IgE serology and should only be given with adequate supervision to prevent adverse systemic allergic reactions. [46]