Asthma Management in Youths and Adults

September 29, 2021

Asthma Management: >= 12 Years of Age

ASTHMA MANAGEMENT: ≥12 YEARS OF AGE
Classifying Asthma Severity and Initiating Treatment
Assessing severity and initiating treatment for patients who are not currently taking long-term control medications
Components of Severity		Classification of Asthma Severity (≥12 Years of Age)
		Intermittent	Persistent
		Intermittent	Mild	Moderate	Severe
Impairment Normal FEV₁/FVC: 8−19yr 85% 20−39yr 80% 40−59yr 75% 60−80yr 70%	Symptoms	≤2 days/week	>2 days/week but not daily	Daily	Throughout the day
	Nighttime awakenings	≤2×/month	3−4×/month	>1×/week but not nightly	Often 7×/week
	Short-acting β₂-agonist use for symptom control (not prevention of EIB)	≤2 days/week	>2 days/week but not daily and not more than 1× on any day	Daily	Several times per day
	Interference with normal activity	None	Minor limitation	Some limitation	Extremely limited
	Lung function	• Normal FEV₁ between exacerbations • FEV₁ >80% predicted • FEV₁/FVC normal	• FEV₁ >80% predicted • FEV₁/FVC normal	• FEV₁ >60% but <80% predicted • FEV₁/FVC reduced 5%	• FEV₁ <60% predicted • FEV₁/FVC reduced >5%
Risk	Exacerbations requiring oral systemic corticosteroids	0−1/year	≥2/year →
Risk	Exacerbations requiring oral systemic corticosteroids	• Consider severity and interval since last exacerbation • Frequency and severity may fluctuate over time for patients in any severity category • Relative annual risk of exacerbations may be related to FEV₁
Recommended Step for Initiating Treatment		Step 1	Step 2	Step 3	Step 4 or 5
		Step 1	Step 2	and consider short course of oral systemic corticosteroids
		In 2−6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

Stepwise Approach for Managing Asthma
Intermittent Asthma	Persistent Asthma: Daily Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3.					↑ Step up if needed (first, check adherence, environmental control, and comorbid conditions) ———————— Assess control ———————— Step down if possible (and asthma is well controlled at least 3 months) ↓
					Step 6 *Preferred:** High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies
				Step 5 *Preferred:* High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies
			Step 4 *Preferred:* Medium-dose ICS + LABA *Alternative:* Medium-dose ICS + either LTRA, Theophylline, or Zileuton
		Step 3 *Preferred:* Low-dose ICS + LABA OR Medium-dose ICS *Alternative:* Low-dose ICS + either LTRA, Theophylline, or Zileuton
	Step 2 *Preferred:* Low-dose ICS *Alternative:* Cromolyn, LTRA, or Theophylline
Step 1 *Preferred:* SABA PRN
Each Step: Patient education, environmental control, and management of comorbidities Steps 2−4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma.
Quick-Relief Medication for All Patients • SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20‑min intervals as needed. Short course of oral systemic corticosteroids may be needed • Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment
NOTES
Key: EIB = exercise-induced bronchospasm; FEV₁ = forced expiratory volume in 1 second; FVC = forced vital capacity; ICS = inhaled corticosteroid; LABA = inhaled long-acting β₂‑agonist; LTRA = leukotriene receptor antagonist; SABA = inhaled short-acting β₂‑agonist. Preferred therapy is based on Expert Panel Report 2* from 1997.

Assessing Asthma Control and Adjusting Therapy
Components of Control		Classification of Asthma Control (≥12 Years of Age)
Components of Control		Well Controlled	Not Well Controlled	Very Poorly Controlled
Impairment	Symptoms	≤2 days/week	>2 days/week	Throughout the day
	Nighttime awakenings	≤2×/month	1−3×/week	≥4×/week
	Interference with normal activity	None	Some limitation	Extremely limited
	Short-acting β₂-agonist use for symptom control (not prevention of EIB)	≤2 days/week	>2 days/week	Several times per day
	FEV₁ or peak flow	>80% predicted/ personal best	60%−80% predicted/ personal best	<60% predicted/ personal best
	Validated questionnaires* ATAQ ACQ ACT	0 ≤0.75† ≥20	1−2 ≥1.5 16−19	3−4 N/A ≤15
Risk	Exacerbations requiring oral systemic corticosteroids	0−1/year	≥2/year →
	Exacerbations requiring oral systemic corticosteroids	Consider severity and interval since last exacerbation
	Progressive loss of lung function	Evaluation requires long-term follow-up care
	Treatment-related adverse effects	Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action for Treatment		• Maintain current step • Regular follow‑ups every 1−6 months to maintain control • Consider step down if well controlled for at least 3 months	• Step up 1 step and • Reevaluate in 2−6 weeks • For side effects, consider alternative treatment options	• Consider short course of oral systemic corticosteroids • Step up 1 to 2 steps and • Reevaluate in 2 weeks • For side effects, consider alternative treatment options
		NOTES
		Key: ACQ = Asthma Control Questionnaire®; ACT = Asthma Control Test™; ATAQ = Asthma Therapy Assessment Questionnaire®; EIB = exercise-induced bronchospasm; FEV₁ = forced expiratory volume in 1 second. *Questionnaires do not assess lung function or the risk domain. †ACQ values of 0.76−1.4 are indeterminate regarding well-controlled asthma.
REFERENCES
Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007. U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/ asthma/asthgdln.pdf. Accessed on: July 19, 2019. (Rev. 8/2019)