Asthma — maintenance

Use at a glance

• Every patient needs ICS-containing therapy

Escalation / refractory disease

• Add LABA before simply escalating ICS greatly

Choosing treatment

• Preferred reliever: ICS-formoterol when available
• MART/SMART if symptoms/exacerbations persist
• LAMA/biologic for selected uncontrolled disease

Safety / pitfalls

• Check adherence + inhaler technique first
• Avoid SABA-only treatment

Key points

• SABA PRN for acute symptoms and EIB prevention
• PRN low-dose ICS + SABA, or ICS/formoterol, ↓ exacerbations vs SABA alone
• ICS most effective maintenance at any severity; daily low-dose ↓ inflammation, symptoms, exacerbations
• Still symptomatic on adherent, well-used ICS → ICS/LABA + SABA or ICS/formoterol MART
• Uncontrolled on medium/high-dose ICS/LABA → add LAMA for lung function
• Moderate-severe allergic: omalizumab (anti-IgE); eosinophilic: anti-IL-5 mepolizumab/reslizumab/benralizumab or dupilumab ↓ exacerbations, OCS
• Severe asthma ≥12 yr: add tezepelumab (anti-TSLP); allergen immunotherapy may help allergic asthma

Nonpharmacologic therapies

• Allergen immunotherapy
• Bronchial thermoplasty
• Spacer with MDI
• Mouth rinsing after ICS
• Inhaler technique and adherence
• Trigger and comorbidity management

Pearls

• Levalbuterol no better than racemic albuterol
• Zileuton: most hepatotoxic leukotriene drug; reserved add-on
• Biologics work best with elevated blood eosinophils
• Asthma biologics generally fine in pregnancy and breastfeeding
• Fluticasone, ciclesonide slow child growth less than budesonide

Self-check

• What is checked before escalating asthma maintenance?
  Adherence + inhaler technique first.
• Which reliever-only strategy is avoided in asthma maintenance?
  SABA-only treatment.

Drugs used for this (24)

All clinical uses · Open Asthma — maintenance in the interactive console ↗