Version July 2025
This figure summarizes our suggested approach to follow-up of adults and adolescents with nonsevere asthma. Patients with severe asthma (requiring step 5 therapy or poorly controlled despite step 5 therapy) should be referred to a severe asthma center for further evaluation and management, including possible treatment with biologic therapies.
This algorithm is intended for use in conjunction with additional UpToDate content. For additional details, refer to UpToDate topics on the ongoing management of asthma therapies.
ICS: inhaled corticosteroid; ICU: intensive care unit: LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; LTRA: leukotriene antagonist; SABA: short-acting beta-agonist.
* For many patients, therapeutic adjustment for poor control will involve stepping up asthma controller therapy. However, some patients may instead merit a change in reliever strategy, trigger avoidance, or inhaler technique without stepping up controller therapy. For detailed discussion of adjusting therapy, please see UpToDate content on ongoing monitoring and management of asthma therapy in adolescents and adults.
¶ Before stepping down therapy, patients should be stable on their current regimen for at least four to six months and typically longer if they have had exacerbations in the last 12 months or have impaired lung function. For additional guidance on stepping down therapy, please see UpToDate content on the ongoing management of asthma therapy in adolescents and adults.
Δ Most asthma patients have symptoms that are fairly congruent with lung function as seen on spirometry. A minority of patients are "low perceivers" who have significant reversible obstruction suggestive of active asthma with minimal symptoms. Others are "high perceivers" who may mistake other factors contributing to shortness of breath for asthma. For patients with these symptom patterns, objective data with spirometry are particularly useful to follow when titrating therapy.
◊ Routine office visits for asthma should include assessment of the following: asthma control, medication adherence, inhaler technique, patient-specific asthma triggers, and risk factors for exacerbations. Asthma patient education, including an asthma action plan, should be provided. For those on inhaled glucocorticoids, clinical surveillance for potential side effects including dysphonia, oral candidiasis, adrenal suppression, cataract development, and osteoporosis is appropriate.
§ Patients using scheduled maintenance therapies (typically LTRA, ICS, or ICS-LABA) should have spirometry annually to assess lung function. Those on reliever therapy alone need less frequent testing if they remain well-controlled.
