An overview of pharmacologic treatment recommendations
- Consider the type of inhaler device that a patient prefers to use and can use properly before prescribing asthma medication
- All asthmatics should have access to a releiver to treat acute symptoms
- In Canada, short-acting beta-agonists (SABAs; salbutamol, terbutaline), and a combination inhaler (bud/form) are approved for this indication.As needed bud/form is approved for use as a reliever in adults and children ≥12 years of age (in Canada).
- Bud/form should not be used as a reliever when controller medications other than maintenance bud/form are used.
- SABAs should only be used for symptom relief and should not be regularly used “to open the airways” before daily controller therapy administration.
- The safest and minimum effective inhaled corticosteroids (ICS) dose that achieves the goals of current control and eliminates exacerbations, should be prescribed to minimize side effects (all groups).
- In poorly controlled asthma cases , potential should be assessed and corrected prior to or in conjunction with escalation of pharmacologic therapy.
Patients not on controller therapy
- Well controlled on SABA or no medication with a lower risk for exacerbations : Continue PRN SABA or be switched to either daily ICS + PRN SABA (all ages) or PRN bud/form (≥12 years of age
- Well-controlled on PRN SABA or no medication with higher risk for exacerbations : Should not be on PRN SABA; switch to daily ICS + PRN SABA (all ages) or PRN bud/form (≥ 12 years of age)
- Not controlled on PRN SABA or no medication : Daily ICS + PRN SABA
- Second line to daily ICS : Leukotriene receptor antagonists (LTRAs) in patients of all ages
Patients not achieving control on low dose ICS
Children not achieving asthma control despite adherence to low dose ICS should be increased to medium dose ICS.
| Maintenance therapy | Recommended controller step-up therapy |
|---|---|
| Preschoolers (under 6 years of age) and children (6 to 11 years of age) | |
| No maintenance | • No step up in controller medication • Consider starting regular controller therapy |
| ICS or LTRA or ICS/LABA** | • No step up in controller medication • In children with a history of severe exacerbation in last year and who fail to respond to SABA, consider prednisone/ prednisolone 1 mg/kg x 3-5 days* |
| Adults (12 years of age and older) | |
| No maintenance | • No step up in controller • Consider starting regular controller therapy or PRN bud/form |
| As needed bud/form | Increase bud/form to a maximum of 8 inhalations per day |
| Daily ICS or LTRA | In individuals ≥16 years of age and older with a history of a severe exacerbation in the last year: • 1 choice: trial of 24 fold increase in ICS for 7 to 14 days. • 2nd choice: Prednisone 30-50 mg for at least 5 days Otherwise no step up in controller medication. |
| Daily bud/form | • 1st choice: Increase bud/form to a maximum of 4 inhalations twice daily for 7 to 14 days (≥16 years of age and older) or use bud/form as reliever and a controller (maximum 8 inhalations per day) (≥12 years of age and older) • 2nd choice: Prednisone 30-50 mg for at least 5 days” |
| Daily fluticasone propionate/ salmeterol, mometasone/ formoterol, fluticasone furoate/vilanterol | In individuals ≥16 years of age with a history of a severe exacerbation in the last year: • 1″ cholce: trial of 24 fold increase in ICS (higher ICS strength of ICS/LABA combination or extra ICS) for 7 to 14 days • 2nd choice: Prednisone 30-50mg for at least 5 days” Otherwise no step up in controller medication. |
| “If regular need for step up therapy or need for a course of systemic steroids, address reasons for poor control and reassess/initiate controller therapy. “Does not apply to preschoolers. | |