Stepwise Management of Asthma

Patients Over 5 Years

Step 4: Severe Persistent	Preferred treatments are in bold lettering Daily Medications: Anti-inflammatory: inhaled steroid (high-dose) AND Long-acting bronchodilator: either long-acting inhaled beta₂-agonist (adult: 2 puffs q 12 hours; child 1-2 puffs q 12 hours), sustained-release theophylline, or long-acting beta₂-agonist tablets AND Steroid tablets or syrup long term; make repeated attempts to reduce systemic steroid and maintain control with high-dose inhaled steroids.
Step 3: Moderate Persistent	Daily Medication: Either Anti-inflammatory: inhaled steroid (medium dose) OR Inhaled steroid (low to medium dose) and add a long-acting bronchdilator, especially for nighttime symptoms: either long-acting inhaled beta₂-agonist (adult: 2 puffs q 12 hours; child 1-2 puffs q 12 hours), and sustained-release theophylline, or long-acting beta₂-agonist tablets. If needed Anti-inflammatory: inhaled steroids (medium to high dose) AND Long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta₂-agonist, sustained-release theophylline, or long-acting beta₂-agonist tablets.
Step 2: Mild Persistent	Daily Medication Anti-inflammatory: either inhaled steroid (low dose) or cromolyn (adult 2-4 puffs tid-qid; child 1-2 puffs tid-qid) or nedocromil (adult: 2-4 puffs bid-qid; child 1-2 puffs bid-qid); children usually begin with a trial of cromolyn or nedocromil. Sustained-release theophylline to serum concentration of of 5-15 mcg/mL is an alternative, but not preferred, therapy at the time this is written. Zafirlukast or zileuton may also be considered for those => 12 years old, although their position in therapy is not fully established.
Step 1: Mild Intermittent	No Daily Medication is needed.
All Patients	Short-acting bronchodilator: inhaled beta₂-agonist (2-4 puffs) as needed for symptoms. Intensity of treatment will depend on severity of exacerbation.

Also see chart of steroid strengths.

The stepwise approach presents general guidelines to assist clinical decision making. Asthma is highly variable; clinicians should tailor medication plans to the needs of individual patients.
Gain control as quickly as possible. Either start with aggressive therapy (e.g., add a course of oral steroids or a higher dose of inhaled steroids to the therapy that corresponds to the patient's initial step of severity); or start the step that corresponds to the patient's initial severity and step up treatment, if necessary.
Step down: Review treatment every 1 to 6 months. Gradually decreased treatment to the least medication necessary to maintain control.
Step up: If control is not maintained, consider step up. Inadequate control is indicated by increased use of short-acting beta₂-agonists and in step 1 when patient uses more that 3 to 4 times in one day. But before stepping up, review patient inhaler technique, compliance, and environmental control (allergen and irritant avoidance)
A course of oral steroids may be needed at any time and at any step.
Patients with exercise-induced bronchospasm should take two to four puffs of an inhaled beta₂-agonist 5 to 60 minutes before exercise.
Referral to an asthma specialist for consultation of comanagement is recommended if there is difficulty maintaining control or if the patient requires step 4 care. Referral may be considered for step 3 care.

This page is based on the Practical Guide for the Diagnosis and Management of Asthma, a publication of the National Heart, Lung and Blood Institute of the National Institutes of Health of the United States
NIH Publication No. 97-4053, October 1997

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