Version July 2025
| Qualifying criteria for stepping-up therapy | Poor asthma control* or high risk of exacerbation¶ on current step therapy despite:
| ||||
| Qualifying criteria for stepping-down therapy | Asthma is well controlled on current therapy, as indicated by presence of all of the following, for at least 3 months:
| ||||
| Step 1 | Step 2 | Step 3 | Step 4 | ||
| Reliever therapy | SABA as needed | SABA as needed | SABA as needed | SABA as needed | |
| Controller therapy | Preferred | A short course of a daily medium-dose ICS beginning at the start of a respiratory tract infection | Daily low-dose ICS | Daily medium-dose ICS or Daily low-dose ICS-LABA | Daily high-dose ICS or Daily medium-dose ICS-LABA |
| or | or | or | or | or | |
| Alternative | (No maintenance regimen) | Intermittent low-dose ICS used whenever a SABA is used or Daily LTRAΔ | Daily low-dose ICS plus LTRAΔ | Daily medium-dose ICS plus LTRAΔ | |
This table illustrates a suggested approach to modifying asthma therapy. Step-down therapy is considered when asthma control has been achieved for at least 3 months. A longer period of control is preferred before decreasing therapy in patients whose asthma was more severe and/or difficult to control or who are still exposed to potential triggers. In children, step-down therapy is more commonly attempted in the summer but may be delayed at the start of the school year or the onset of the winter viral respiratory infection season. Treatment with controller medications may be escalated, or stepped up, at any time if poor asthma control is identified after assessing modifiable factors including adherence, inhaler technique, adverse effects of medications, environmental triggers, and comorbid conditions. Consider alternative diagnoses if control is inadequate despite optimal therapy. Subcutaneous immunotherapy with specific environmental allergens is suggested as an adjunct to standard pharmacotherapy in persons who have demonstrated allergy to the included allergens. Immunotherapy should not be administered if the patient's asthma is not well controlled. Consultation with an asthma specialist is recommended if step 3 or higher is required. For children whose asthma is still not controlled on step 4 therapy, additional medication options include a trial of increasing the dose of daily ICS to high dose if on medium dose, adding an LABA or LTRA if the child is not already on one of these, and, lastly, adding oral glucocorticoids.
Therapeutic strategies for patients with newly diagnosed asthma are covered separately. Dosing information can be found in separate dosing tables. For additional information, refer to UpToDate content on initial and ongoing treatment of asthma.
ICS: inhaled corticosteroid (glucocorticoid); LABA: long-acting beta agonist; LTRA: leukotriene receptor antagonist; SABA: short-acting beta agonist.
* Poor asthma control is generally defined as having daytime symptoms more than 2 days/week, nocturnal awakenings due to asthma more than once a month, some degree of limitation in activities, use of SABA for symptoms more than 2 days/week, or at least 2 asthma exacerbations per year that require treatment with systemic glucocorticoids. Children with poor asthma control who are not on the preferred step therapy can be switched to that therapy rather than immediately stepping up therapy. In children with very poor asthma control, a short course of oral glucocorticoids and/or stepping up 2 steps may be necessary to attain asthma control.
¶ Exacerbations are defined as use of systemic (oral or parenteral) glucocorticoids, emergency department visits, and/or hospitalizations for asthma. 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. Please refer to UpToDate asthma treatment content and separate graphic on risk factors for asthma exacerbation for additional information.
Δ Serious neuropsychiatric events, including suicidal thoughts or actions, have been reported with montelukast.
