Simplified approach to initial asthma therapy in adolescents and adults

		Step 1	Step 2	Step 3	Step 4
	Qualifying criteria	All of the following at initiation of therapy or using SABA alone: Daytime symptoms ≤2 days/week Nocturnal awakenings ≤2/month Normal FEV₁ Exacerbations ≤1/year	Any of the following: Daytime asthma symptoms 3 to 6 days per week Two to four nocturnal awakenings per month due to asthma (but not more than once weekly) Minimal interference with normal activities Two or more exacerbations requiring oral glucocorticoids per year	Any of the following: Daily symptoms of asthma Nocturnal awakenings more than once per week Occasional limitation in normal activity Evidence of airway obstruction outside of an exacerbation (eg, FEV₁ between 60 and 80% of predicted or z-score –1.65 to –2.5 with an abnormally low FEV₁/FVC ratio)	Any of the following: Frequent limitation in normal activity due to asthma symptoms Nightly awakenings Evidence of moderate to severe airway obstruction (FEV₁ <60% predicted or z-score <–2.5 with an abnormally low FEV₁/FVC ratio)
Option 1	ICS-formoterol regimen	Low-dose ICS-formoterol^* as needed	Low-dose ICS-formoterol^* as needed	Low-dose ICS-formoterol as maintenance and reliever therapy (preferred)^¶	Medium-dose ICS-formoterol as maintenance and reliever therapy (preferred)^¶
Option 2	Alternative maintenance regimens	(No maintenance regimen)	(Anti-inflammatory reliever therapy without a maintenance regimen)^*Δ or Low-dose ICS (daily or twice daily)	Low-dose ICS-LABA (preferred alternative) or Low-dose ICS plus LAMA or LTRA	Medium-dose ICS-LABA (preferred alternative) or Medium-dose ICS plus LAMA or LTRA
	and	and	and	and	and
	Alternative reliever regimens	ICS-SABA as needed^* or ICS plus SABA as needed^* (preferred alternative reliever options) or SABA, as needed	ICS-SABA as needed^Δ or ICS plus* SABA as needed^*Δ (preferred alternative reliever options) or SABA, as needed	ICS-SABA as needed^* or ICS plus SABA as needed^* (preferred alternative reliever options) or SABA, as needed	ICS-SABA as needed^* or ICS plus SABA as needed^* (preferred alternative reliever options) or SABA, as needed

This table illustrates simplified recommendations for initiating asthma therapy based on the frequency and severity of asthma symptoms. This table may also be used to guide therapeutic adjustments in patients using SABA alone (without any controller therapy). The response to therapy should be assessed in 2 to 12 weeks depending on clinical urgency. At follow-up visits, check adherence, inhaler technique, environmental factors, and comorbid conditions. Subcutaneous immunotherapy is suggested as an adjunct to standard pharmacotherapy in individuals who have demonstrated allergy to the included allergens and whose asthma is well controlled whenever immunotherapy is administered. Consult with an asthma specialist for patients not controlled on step 4 therapy.

Additional strategies for ongoing asthma treatment may be found in the accompanying graphic on guideline approaches to initial asthma therapy. Dosing information can be found in separate dosing tables for SABA, AIR, MART, inhaled glucocorticoids, and inhaled glucocorticoids combined with bronchodilators. For additional information, please refer to UpToDate content on initial and ongoing treatment of asthma in adolescents and adults.

AIR: anti-inflammatory reliever; DPI: dry powder inhaler; FEV₁: forced expiratory volume in one second; ICS: inhaled corticosteroid (glucocorticoid); IgE: immunoglobulin E; IL: interleukin; LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; LTRA: leukotriene receptor antagonist; MART: maintenance and reliever therapy; MDI: metered-dose inhaler; SABA: short-acting beta-agonist.

* When prescribed for use as-needed for acute asthma symptoms, ICS-formoterol, ICS-SABA, and concomitant ICS and SABA use are referred to as AIR therapy. Compared with SABA relievers, use of AIR has demonstrated decreased exacerbation risk in patients with all degrees of asthma severity. Choice of therapy is also guided by patient preference, cost, and medication availability. LABAs other than formoterol cannot be used for AIR due to their more prolonged onset of action. Patients with risk factors for exacerbations, variable symptoms, or poor adherence to maintenance therapies are particularly likely to benefit from AIR, but choice of therapy is also guided by patient preference, cost, and medication availability.

Risk factors for exacerbations include: poor asthma symptom control, a history of asthma exacerbation on the current regimen, smoking, allergen exposure if sensitized, previous intubation or intensive care unit stay for asthma, low FEV₁ (especially <60% predicted), obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique. Please refer to UpToDate asthma treatment content and separate graphic on risk factors for asthma exacerbation for additional information.

¶ ICS-formoterol prescribed for use as both maintenance therapy and for acute relief of symptoms is referred to as MART. MART has been shown to be more effective in terms of exacerbation reduction and symptom relief compared with ICS-formoterol and SABA alone as reliever therapy. Choice of therapy is also guided by patient preference, cost, and medication availability. LABAs other than formoterol cannot be used for MART due to their more prolonged onset of action.

Δ For patients qualifying for step 2 therapy, only AIR (ICS-formoterol, ICS-SABA, and concomitant ICS and SABA) should be used without concomitant maintenance low-dose inhaled glucocorticoid therapy. These patients should not be treated with SABA alone.

References:

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Revised August 2007 (NIH publication no. 07-4051). Available at: https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma (Accessed November 3, 2023).
National Heart, Lung, and Blood Institute. 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. December 2020 (NIH publication no. 20-HL-8140). Available at: https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates (Accessed November 3, 2023).
Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2023. Updated July 2023. Available at: https://ginasthma.org/2023-gina-main-report/ (Accessed November 8, 2023).

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Simplified approach to initial asthma therapy in adolescents and adults