Asthma Treatment Guidelines

Long-term asthma management

The medications in the asthma treatment guidelines as proposed and promulgated by the NAEPP require use a stepwise fashion. The last word in treatment is the clinicians’ decision making based on the needs of the patient and the stepwise approach is merely to assist the physician and not replace his judgment. If alternative treatment is initiated first and is not effective, the preferred treatment must be used before going on to the next STEP.

Managing Asthma Long Term in Adults and Youths ≥12 Years
I highly recommend checking out this free PDF available from National Heart, Lung, & Blood Institute. You'll find an excellent chart of these asthma treatment guidelines, Figure 4-5, on the 18th page of the document (p. 343 of the whole report)
Managing Asthma Long Term in Youths ≥12 Years of Age and Adults



Asthma Treatment Guidelines:

The 6 Steps of Pharmacological Asthma Management

(6) STEPS are used in the pharmacological management of asthma. Each STEP is preceded by patient education, environmental control, and treatment of any co-morbidities that may exist.

Quick-relief medication is used in all STEPS. The treatment used depends on the severity of the symptoms.

Short-acting beta agonists (SABA) are used as needed for 20 minutes up to 3 times per day. If SABAs need to be used for more than 2 days a week, treatment is considered inadequate and there must be a step-up in treatment. However, if the patient is suffering from exercise-induced asthma (EIA) and SABAs are used only for treatment of EIB, this caveat does not apply.

STEP 1

This STEP is used when the patient suffers from Intermittent Asthma and includes the use of a SABA as needed (prn) as the preferred treatment.

STEP 2

This STEP is used when the patient suffers from Persistent Asthma and includes a low dose inhaled corticosteroid (ICS) on a daily basis as the preferred treatment. Alternative treatment includes Cromolyn, Leukotriene receptor antagonist (LTRA), Nedocromil, or theophylline. In STEPS 2 to 4, immunotherapy (subcutaneous) can be used for treatment of single allergens such as house-dust mites, animal danders, and pollens.

STEP 3

This STEP is used when the patient suffers from Persistent Asthma and includes a low-dose ICS and LABA or a medium-dose ICS on a daily basis as the preferred treatment. Alternative treatment includes low-dose ICS and either LTRA, Theophylline, or Zileuton. Zileuton requires monitoring of liver function and Theophylline requires monitoring of serum concentration levels. Immunotherapy (subcutaneous) can be used in this STEP (see STEP 2).

STEP 4

This STEP is used when the patient suffers from Persistent Asthma and includes a medium-dose ICS and LABA on a daily basis as the preferred treatment. Alternative treatment includes medium-dose ICS and either LTRA, Theophylline, or Zileuton (see STEP 3).Immunotherapy (subcutaneous) can be used in this STEP (see STEP 2).

STEP 5

This STEP is used when the patient suffers from Persistent Asthma and includes a high-dose ICS and a LABA on a daily basis as the preferred treatment. Omalizumab can also be considered in patients with allergies. If Omalizumab is used the treating physician must be prepared and equipped to diagnose and treat anaphylaxis which can occur with this medication.

STEP 6

This step is used when the patient suffers from Persistent Asthma and includes a high-dose ICS and LABA and an oral corticosteroid on a daily basis. Omalizumab can also be considered in patients with allergies (See STEP 5).

In all STEPS of these asthma treatment guidelines, always assess control of asthma and step up medication if needed, providing patient is taking medication properly, environmental factors are controlled, and co-morbid conditions are adequately treated. If the assessment of asthma control shows that asthma is well controlled for at least 3 months, then a step down may be possible.

If a patient is placed in category STEP 4 or above a consult with an asthma specialist is required, but should be considered at STEP 3.


References:

This presentation is modeled in part after the following:

National Asthma Education and Prevention Program
Expert panel Report 3:
Guidelines for the Diagnosis and Management of Asthma
Full Report 2007

U. S. Department of Health and Human Services
National Institutes of Health
National Heart, Lung and Blood Institute

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