Asthma Management: During Pregnancy and Lactation

ASTHMA MANAGEMENT: DURING PREGNANCY AND LACTATION
Goals of Therapy: Asthma Control
• Minimal or no chronic symptoms day or night • Minimal or no exacerbations • No limitations on activities: no school/work missed			• Maintain (near) normal pulmonary function • Minimal use of short-acting inhaled beta₂‑agonists³ • Minimal or no adverse effects from medications
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT
Components of Severity	Classification of Asthma Severity During Pregnancy and Lactation
	Mild Intermittent	Persistent
	Mild Intermittent	Mild		Moderate	Severe
Symptoms/Day	≤2 days/week	>2 days/week but < daily		Daily	Continual
Symptoms/Night	≤2 nights/month	>2 nights/month		>1 night/week	Frequent
PEF or FEV₁	≥80%	≥80%		>60%−<80%	≤60%
PEF Variability	<20%	20%−30%		>30%	>30%
STEPWISE APPROACH FOR MANAGING ASTHMA
Intermittent Asthma	Persistent Asthma				↑ Step up If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control. ———————— Assess control ———————— Step down Review treatment every 1−6 months; a gradual stepwise reduction in treatment may be possible. ↓
				Step 4 (Severe Persistent) *Preferred treatment:* High-dose inhaled corticosteroid AND Long-acting inhaled beta₂‑agonist AND, if needed, Corticosteroid tablets or syrup long term (2mg/kg/day, generally not to exceed 60mg/day). (Make repeat attempts to reduce systemic corticosteroid and maintain control with high‑dose inhaled corticosteroid.¹) *Alternative treatment:* High-dose inhaled corticosteroid¹ AND theophylline⁴ AND, if needed, oral corticosteroids
		Step 3 (Moderate Persistent) *Preferred treatment:* EITHER Low-dose inhaled corticosteroid¹ and long‑acting inhaled beta₂‑agonist OR Medium-dose inhaled corticosteroid.¹ If needed (particularly in patients with recurring severe exacerbations): Medium‑dose inhaled corticosteroid¹ and long‑acting inhaled beta₂‑agonist *Alternative treatment:* Low-dose inhaled corticosteroid¹ and either theophylline⁴ or leukotriene receptor antagonist.² If needed: Medium‑dose inhaled corticosteroid¹ and either theophylline⁴ or leukotriene receptor antagonist.²
	Step 2 (Mild Persistent) *Preferred treatment:* Low-dose inhaled corticosteroid.¹ Alternative treatment (listed alphabetically): cromolyn, leukotriene receptor antagonist² OR theophylline⁴
Step 1 (Mild Intermittent) No daily medications, albuterol as needed.
Quick-Relief Medication for All Patients • Short-acting bronchodilator: 2−4 puffs short-acting beta₂‑agonist³ as needed for symptoms. • Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20‑minute intervals or a single nebulizer treatment as needed. Course of systemic corticosteroid may be needed. • Use of short-acting inhaled beta₂‑agonist³ >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term-control therapy.
Additional Information
• The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs. • Classify severity: assign patient to most severe step in which any feature occurs (PEF is percent of personal best; FEV₁ is percent predicted). • Gain control as quickly as possible (consider a short course of systemic corticosteroid), then step down to the least medication necessary to maintain control. • Minimize use of short-acting inhaled beta₂‑agonist³ (eg, use of approximately one canister a month even if not using it every day indicates inadequate control of asthma and the need to initiate or intensify long-term-control therapy). • Provide education on self-management and controlling environmental factors that make asthma worse (e.g., allergens, irritants). • Refer to an asthma specialist if there are difficulties controlling asthma or if Step 4 care is required. Referral may be considered if Step 3 care is required.
NOTES
¹Budesonide is the preferred inhaled corticosteroid for use during pregnancy. However, pregnant patients whose asthma was well controlled on other inhaled corticosteroids before pregnancy may continue their treatment. ²There are minimal data on using leukotriene receptor antagonists in humans during pregnancy, although there are reassuring animal data submitted to FDA. ³There are more data on using albuterol during pregnancy than on using other short-acting inhaled beta₂‑agonists. ⁴Achieve theophylline serum concentration 5−12mcg/mL.
REFERENCES
American College of Obstetricians and Gynecologists. Asthma in Pregnancy. ACOG Practice Bulletin No. 90. Obstet Gynecol 2008; 111:457-64. National Asthma Education and Prevention Program. Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment 2004. U.S. Department of Health and Human Services. http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_full.pdf. Accessed November 26, 2012. (Rev. 4/2018)

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