Bronchial Asthma: Stepwise Management in Adults

Pharmacological management of asthma is offered as a stepwise therapy. Health-care professionals advise their patients with bronchial asthma to begin treatment at the step most suitable to the initial severity of the condition. They may ask to move up stepwise to improve asthma control as needed or move down stepwise to look for and keep up lowest controlling step. If the response to therapy is inadequate, it is better to check compliance to medication and reconsider the diagnosis.

Step 1

This step is suitable to manage mild intermittent bronchial asthma. Mild intermittent asthma is described as getting symptoms fewer than once weekly, and getting FEV1 (forced expiratory volume in one second) or PEF (peak expiratory flow) is 80 % of the predicted value with a less than 20 % variability. An inhaled short-acting β2 agonist (SABA) like Salbutamol is recommended at this step.

If asthma control is inadequate with step 1,

Check inhaler technique and correct it.
Check compliance to the medication.
Move up to step 2, if inhaler technique and compliance are satisfactory.

Step 2

This step is appropriate to patients, who cannot control bronchial asthma with step 1. Patients are asked to add inhaled steroid (Beclometasone dipropionate, Budesonide, Fluticasone propionate, or Mometasone furoate) 200-800 µg/day as a regular preventer therapy. The dose of 400 µg is adequate for most patients. Health-care professionals will ask to begin at a dose of inhaled steroid suitable to severity of asthma.

If asthma control is inadequate with step 2,

Check inhaler technique and correct it.
Check compliance to medications.
Move up to step 3, if inhaler technique and compliance are satisfactory.

Consider moving down to step 1, if asthma control is adequate with step 2.

Step 3

Step 3 is suitable to patients, who cannot control asthma with step 2. Health-care professionals will ask to add an inhaled long-acting β2 agonist (LABA) such as Formoterol or Salmeterol as an initial add-on therapy. They assess control of bronchial asthma with LABA. If there is a good response, the patient will be asked to continue LABA. If there are some benefits from LABA but asthma control is still poor, the patient needs to continue LABA and increase the dose of inhaled steroid (Beclometasone dipropionate or equivalent) to 800 µg/day (if the patient is already not on this dose).

If there is no response to LABA, the patient needs to quit LABA and increase the dose of inhaled steroid to 800 µg/day.

If control is still poor, health-care professionals will start trial of other medications like leukotriene receptor antagonist (Montelukast or Zafirlukast) or theophylline sustained-release (SR) tablets.

If asthma control is inadequate with step 3,

Check inhaler technique and correct it.
Check compliance to medications.
Move up to step 4, if inhaler technique and compliance are satisfactory.

Consider moving down to step 2, if asthma control is adequate with step 3.

Step 4

Step 4 is appropriate to patients with persistent poor control of bronchial asthma. At this step, health-care professionals will consider some trials of medications such as increasing inhaled steroid (Beclometasone dipropionate or equivalent) up to 2000 µg/day and inclusion of a fourth medication (leukotriene receptor antagonist, Theophylline SR, or β2 agonist tablets such as Salbutamol, Terbutaline, and Bambuterol).

If asthma control is inadequate with step 4,

Check inhaler technique and correct it.
Check compliance to medications.
Move up to step 5, if inhaler technique and compliance are satisfactory.

Consider moving down to step 3, if asthma control is adequate with step 4.

Step 5

Step 5 includes frequent or continuous use of steroid tablets and suitable to patients, who cannot control bronchial asthma with step 4. Patients will be offered daily steroid tablets in lowest dose giving sufficient control. They will be asked to keep up high dose of inhaled steroid (Beclometasone dipropionate or equivalent) at 2000 µg/day. Health-care professionals will consider other treatments to reduce the use of steroids and arrange a specialist referral for further management.

If asthma control is inadequate with step 5,