Asthma

Table 3. Stepwise Approach for Managing Asthma – Youth ≥ 12 Years of Age and Adults Persistent Asthma: Daily Medication Intermittent Asthma 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 Step 1 Preferred: SABA prn Preferred: Low-dose ICS Alternative: LTRA, Cromolyn, Nedocromil, or Theophylline Preferred: Medium- dose ICS OR Low-dose ICS + LABA† Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Preferred: Medium- dose ICS + LABA† Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton Preferred: High-dose ICS + LABA† AND Consider Omalizumab for patients who have allergies Preferred: High-dose ICS + LABA† + oral systemic corticosteroid Alternative: High dose ICS + either LTRA, or Theophylline + oral corticosteroid AND Consider Omalizumab for patients who have allergies Patient education and environmental control at each step Quick-Relief Medication for All Patients > SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. > Caution: Increasing use of beta-agonist or use > 2 times a week for symptom control (not prevention of exercise-induced bronchospasm) indicates inadequate control and the need to step up treatment. ICS, inhaled corticosteroid; LABA, long-acting β2 needed; SABA, inhaled short-acting β2 -agonist Notes: • The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. • If an alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. • Zileuton is a less desirable alternative 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 corticosteroids are introduced, a trial of high-dose ICS + LABA† + either LTRA, theophyllines, or zileuton may be considered, although this approach has not been studied in clinical trials. • Offering alternative therapies allows for consideration of treatment effectiveness, including relevance to the individual patient, patient's history of previous response to therapies, the ability of the patient and family to use medication correctly, and anticipated family adherance to the treatment regimen. †BLACK BOX WARNING: Long-acting β2 4 -adrenergic agonists may increase the risk of asthma-related death. They should never be used alone in children or adults with asthma. Please see product labeling for information on this warning. An FDA Medication Guide should be distributed to patients starting a new prescription. -agonist; LTRA, leukotriene receptor antagonist; prn, as Step up if needed (first check adherence and environmental control) Assess Control Step down if possible (and asthma is well controlled for ≥ 3 months)

• Cover