• No daily medication needed
• Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroids is recommended.

• Preferred treatment:
  • Low-dose inhaled corticosteroids.
• Alternative treatment (listed alphabetically): cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentrations of 5-15 mcg/ml.

• Preferred treatment:
  • Low-to-medium dose inhaled corticosteroids and long-acting inhaled beta2-agonists.
• Alternative treatment (listed alphabetically):
  • Increase inhaled corticosteroids within medium-dose range

  OR

  • Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophylline

If needed (particularly in patients with recurring severe exacerbations):

• Preferred treatment:
  • Increase inhaled corticosteroids within medium-dose range and add long-acting inhaled beta2-agonists.
• Alternative treatment:
  • Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophylline.
     

• Preferred treatment:
  • High-dose inhaled corticosteroids

  AND

  • Long-acting inhaled beta2-agonists

  AND, if needed

  • Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60mg per day). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)

Quick Relief

All Patients

• Short-acting bronchodilator: 2-4 puffs short-acting inhaled beta2-agonists as needed for symptoms.
• Intensity of treatment will depend on severity of exacerbations; up to 3 treatments at 20-minute intervals or a single nebulizer as needed. Course of systemic corticosteroid may be needed.
• Use of short-acting beta2-agonists >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term therapy.

Note:

• The stepwise approach is intended to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• Classify severity: assign patient to most severe step in which any feature occurs (PEF is % of personal best; FEV1 is % predicted).
• Gain control as quickly as possible (a course of short systemic corticosteroids may be required); then step down to the least medication necessary to maintain control
• Provide education on self-management and controlling environmental factors that make asthma worse (e.g. allergies and irritants)
• Refer to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if step 3 care is required.