The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Assess Asthma Severity to Decide Initial Therapy
Components of Severity |
Intermittent |
Persistent (Mild) |
Persistent (Moderate) |
Persistent (Severe) |
Impairment |
Symptoms |
< 2 days/week |
> 2 days/week, not daily |
Daily |
Throughout day |
Nighttime awakenings |
0 |
1-2x/month |
3-4x/month |
> 1x/week |
Short-acting beta2-agonist use for symptoms |
< 2 days/week |
> 2 days/week, not daily |
Daily |
Several times daily |
Interference with normal activity |
None |
Minor limitations |
Some limitations |
Extremely limited |
Risk |
Exacerbations requiring oral steroids |
0-1/year |
> 2 in 6 months requiring oral steroids, or > 4 in 1 year lasting > 1 day and have risk factors for persistent asthma |
Consider severity & interval since last exacerbation. Frequency & severity may fluctuate over time for patient of any severity class. |
Recommended step for initiating treatment |
Step 1 |
Step 2 |
Step 3 |
Re-evaluate control in 2 to 6 weeks and adjust therapy accordingly. |
On Follow-Up, Assess Asthma Control and Step Therapy Up or Down
Components of Control |
Well-Controlled |
Not Well-Controlled |
Very Poorly Controlled |
Impairment |
Symptoms |
< 2 days/week, but not >1/day |
>2 days/week or many times on <2 days/week |
Throughout day |
Nighttime awakenings |
< 1x/month |
> 1x/month |
> 1x/week |
Short-acting beta2-agonist use for symptoms |
< 2 days/week |
> 2 days/week |
Several times/day |
Interference with normal activity |
None |
Some limitation |
Extremely limited |
Risk |
Exacerbations requiring oral steroids |
0-1x/year |
2-3x/year |
> 3x/year |
Treatment-related adverse effects |
Intensity of medication-related side effects does not correlate to specific levels of control, but should be considered in overall assessment of risk. |
Recommended treatment and follow-up |
- Maintain current step
- Regular follow-up every 1-6 months
- Consider step down if well-controlled >3 months
|
Step up 1 step |
- Consider oral steroids
- Step up 1-2 steps
|
- Re-evaluate in 2-6 weeks
- If no clear benefit in 4-6 weeks, consider alternative diagnosis or adjust therapy [D]
|
Step Approach for Asthma Management (use lowest treatment level required to maintain control)
- Quick relief medication for all patients: Inhaled short-acting beta2-agonist (SABA) as needed for symptoms. Intensity of treatment depends on severity of symptoms; up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. Use of SABA >2 days a week for symptom control (not prevention of exercise-induced bronchospasm) indicates inadequate control and the need to step up treatment.
- Patient education and environmental control at each step
- Persistent asthma: Daily long-term control therapy [A]; consult with asthma specialist step 4 or higher [D]; consider consultation at step 3 [D]
Intermittent Asthma
Step 1
Preferred: Short-acting beta2-agonist as required
Mild Persistent Asthma
Step 2
Preferred: Low-dose inhaled corticosteroid [A]
Alternative: Cromolyn or Montelukast [B]
Moderate Persistent Asthma
Step 3
Preferred: Medium-dose inhaled corticosteroid [D]
Step 4
Preferred: Medium-dose inhaled corticosteroid + either a long-acting beta2-agonist or montelukast [D]
Severe Persistent Asthma
Step 5
Preferred: High-dose inhaled corticosteroid + either a long-acting beta2-agonist or montelukast [D]
Step 6
Preferred: High-dose inhaled corticosteroid + oral systemic corticosteroid + either a long-acting beta2-agonist or montelukast [D]
Definitions:
Levels of Evidence for the Most Significant Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel