Version July 2025
| Step 1 | Step 2 | Step 3 | Step 4 | ||
| Qualifying criteria | All of the following:
| Any of the following:
| Any of the following:
| Any of the following:
| |
| Reliever therapy | Preferred | SABA as needed | SABA as needed | Low-dose ICS-formoterol (fast-onset LABA) as needed (plus daily as controller therapy) | Medium-dose ICS-formoterol (fast-onset LABA) as needed (plus daily as controller therapy) |
| or | or | or | |||
| Alternative | SABA as needed (with alternative controller therapy) | SABA as needed (with alternative controller therapy) | |||
| Controller therapy | Preferred | (No maintenance regimen) | Daily low-dose ICS | Daily low-dose ICS-formoterol (plus as needed) | Daily medium-dose ICS-formoterol (plus as needed) |
| or | or | or | or | or | |
| Alternative(s) | Low-dose ICS whenever SABA is used | Low-dose ICS whenever SABA is used or Daily LTRA* | Daily low-dose ICS-LABA (slower-onset LABA, not formoterol) or Daily medium-dose ICS or Daily low-dose ICS plus LTRA* | Daily medium-dose ICS-LABA (slower-onset LABA, not formoterol) or Daily high-dose ICS or Daily medium-dose ICS plus LTRA* or Daily medium-dose ICS-LABA plus tiotropium or LTRA* | |
This table illustrates a suggested approach to initiating asthma therapy in patients who have never taken any form of long-term controller therapy. The degree of severity while not on long-term controller medications determines which "step" or level of initial therapy is needed. Severity is determined by current impairment and future risk of exacerbations. Risk factors for exacerbations include poor asthma symptom control, a history of asthma exacerbation on the current regimen, tobacco smoke exposure, environmental allergen exposure if sensitized, previous intubation or intensive care unit stay for asthma, obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique. Other factors, including the risk of developing persistent asthma, are also taken into consideration in children under 5 years of age. Choice of therapy is also guided by patient preference, cost, and medication availability. Consultation with an asthma specialist is recommended if step 3 or higher is required.
Patients should be reevaluated after initiation of controller therapy to determine its effectiveness. A reasonable interval is 2 to 4 weeks for patients diagnosed with moderate-to-severe persistent asthma and 4 to 6 weeks for children with mild persistent asthma. At follow-up visits, check adherence and inhaler technique and assess for environmental factors and comorbid conditions.
Additional strategies for initial asthma treatment may be found in UpToDate asthma treatment content. Dosing information can be found in separate dosing tables for SABA and ICS. For additional information, please refer to UpToDate content on initial and ongoing treatment of asthma in children.
FEV1: forced expiratory volume in the first second; FVC: forced vital capacity; ICS: inhaled corticosteroid (glucocorticoid); LABA: long-acting beta agonist; LTRA: leukotriene receptor antagonist; SABA: short-acting beta agonist.
* Serious neuropsychiatric events, including suicidal thoughts or actions, have been reported with montelukast.
