Pharmacological Treatment
Management using the stepwise approach
Pharmacologic management of asthma aims to control symptoms, prevent exacerbations and provide the best possible pulmonary function with minimal medications and side effects. Currently available medications for asthma are generally safe and well tolerated. GINA has outlined a 5-step approach to the pharmacologic management of asthma (See figure 1).1 Each step recommends treatments for the control of asthma based on a patient’s current treatment and level of control. Step 2 is generally the initial step for most treatment-naive patients with persistent symptoms, unless asthma is severely uncontrolled in which case treatment can commence at Step 3.1
Step 1: As needed reliever medication
Step 1 treatment is for patients with occasional symptoms (cough, wheeze, dyspnea) occurring twice a week or less (or less frequently if nocturnal) and with normal lung function.
- An inhaled rapid-acting β2-agonist is recommended as reliever treatment
- An inhaled anticholinergic, short-acting oral β2-agonist, or short-acting theophylline may be considered as alternatives
Step 2: Reliever medication plus a single controller
- Low-dose ICS are the recommended drug for adults and children in achieving treatment goals.
- Leukotriene-receptor antagonists may also be considered at this stage, depending on the age of the patient and their ability to coordinate an inhalation device.
Step 3: Reliever medication plus one or two controllers
- An inhaled LABA is recommended as an add-on to low-dose ICS, either as a separate component or in a fixed-dose combination, for adolescents and adults (LABA should not be used as monotherapy)
- Another approach for adults and especially children is to increase ICS to a medium dose
- If control remains inadequate, consider a sequential trial of add-on therapy, i.e. leukotrienereceptor antagonists and low-dose sustained-release theophyllines
Step 4: Reliever medication plus two or more controllers
Selection of treatment depends on prior selections at Steps 2 and 3, and the order in which additional medications should be added is based, as far as possible, upon evidence of their relative efficacy in clinical trials. Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma.
Step 5: Reliever medication plus additional controller options
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Continuous or frequent use of oral corticosteroids is the recommended controller therapy; however, patients receiving long-term or frequent courses of oral corticosteroids are at risk of systemic adverse events
- Addition of oral glucocorticosteroids to other controller medications may be effective, but is associated with severe side effects and should only be considered if the patient’s asthma remains severely uncontrolled, with daily limitation of activities and frequent exacerbations
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Patients should be counselled about potential side effects and all other alternative treatments must be considered
- Additional factors to be considered in long-term oral corticosteroid use include:1, 2
- Blood pressure should be monitored
- Diabetes mellitus may occur
- Bone density should be monitored and a long-acting biphosphonate should be prescribed
- Growth should be monitored, and cataracts should be screened for in children
- In adults, the recommended method of eliminating or reducing the dosage of oral steroids is by using ICS instead, at doses of up to 2000 µg/day
- In children aged 5–12 years, doses above 1000 µg/day should be considered very carefully
- Addition of anti-IgE therapy to other controller medications is an alternative option for these patients
- Immunosuppressants (methotrexate, cyclosporin and oral gold) may be given as a 3-month trial and should be stopped if no improvement occurs. They should be given in a center experienced in using these medicines.
References:
1. GINA. Global Initiative for Asthma. www.ginasthma.com. 2007.
2. BTS/SIGN. British guideline on the management of asthma. Revised edition. 2005.