Asthma Care Quick Reference: Diagnosing and Managing Asthma

Guidelines from the National Asthma Education and Prevention Program: Expert Panel Report 3

Introduction

Key Clinical Activities for Quality Asthma Care

Asthma Care for Special Circumstances

Managing Exacerbations

Initial Visit: Classifying Asthma Severity and Initiating Therapy

Follow-Up Visits: Assessing Asthma Control and Adjusting Therapy

Stepwise Approach for Managing Asthma Long Term

Estimated Comparative Daily Dosages: Inhaled Corticosteroids for Long-Term Asthma Control

Therapeutic Issues Pertaining to ICS for Long–Term Asthma Control

Usual Dosages for Other Long–Term Control Medications

Responding to Patient Questions about Inhaled Corticosteroids

Responding to Patient Questions about Long–Acting Beta₂–Agonists

Educational Resources

Introduction

The goal of this asthma care quick reference guide is to help clinicians provide quality care to people who have asthma.

Quality asthma care involves not only initial diagnosis and treatment to achieve asthma control, but also long–term, regular follow–up care to maintain control.

Asthma control focuses on two domains: 1) reducing impairment—the frequency and intensity of symptoms and functional limitations currently or recently experienced by a patient; and 2) reducing risk—the likelihood of future asthma attacks, progressive decline in lung function (or, for children, reduced lung growth), or medication side effects.

Achieving and maintaining asthma control requires providing appropriate medication, addressing environmental factors that cause worsening symptoms, helping patients learn self–management skills, and monitoring over the long term to assess control and adjust therapy accordingly.

Following are the steps involved in providing quality asthma care.

Initial Visit

Diagnose asthma
Assess asthma severity
Initiate medication and demonstrate use
Develop written asthma action plan
Schedule follow–up appointment

Follow–up Visits

Assess and monitor asthma control
Review medication technique and adherence; assess side effects; review environmental control
Maintain, step up, or step down medication
Review asthma action plan, revise as needed
Schedule next follow–up appointment

This guide summarizes recommendations developed by the National Asthma Education and Prevention Program's expert panel after conducting a systematic review of the scientific literature on asthma care. See http://www.nhlbi.nih.gov/guidelines/asthma for the full report and references. Medications and dosages were updated in September 2011 for the purposes of this quick reference guide to reflect currently available asthma medications.

Back to table of contents

Key Clinical Activities for Quality Asthma Care

(See complete table in Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma [EPR–3])

Clinical Issue	Key Clinical Activities and Action Steps
Asthma Diagnosis
	Establish asthma diagnosis Determine that symptoms of recurrent airway obstruction are present, based on history and exam. History of cough, recurrent wheezing, recurrent difficulty breathing, recurrent chest tightness Symptoms occur or worsen at night or with exercise, viral infection, exposure to allergens and irritants, changes in weather, hard laughing or crying, stress, or other factors In all patients 5 years of age or older, use spirometry to determine that airway obstruction is at least partially reversible. Consider other causes of obstruction.
Long–term Asthma Management
GOAL: Asthma Control	Reduce Impairment Prevent chronic symptoms. Require infrequent use of short–acting beta₂–agonist (SABA). Maintain (near) normal lung function and normal activity levels. Reduce Risk Prevent exacerbations. Minimize need for emergency care, hospitalization. Prevent loss of lung function (or, for children, prevent reduced lung growth). Minimize adverse effects of therapy.
Assessment and Monitoring	INITIAL VISIT: Assess asthma severity to initiate treatment (see page 5). FOLLOW–UP VISITS: Assess asthma control to determine if therapy should be adjusted (see page 6). Assess at each visit: asthma control, proper medication technique, written asthma action plan, patient adherence, patient concerns. Obtain lung function measures by spirometry at least every 1 to 2 years; more frequently for asthma that is not–well–controlled. Determine if therapy should be adjusted: Maintain treatment; step up, if needed; step down, if possible. Schedule follow–up care Asthma is highly variable over time. See patients: Every 2 to 6 weeks while gaining control Every 1 to 6 months to monitor control Every 3 months if step down in therapy is anticipated
Use of Medications	Select medication and delivery devices that meet patient's needs and circumstances. Use stepwise approach to identify appropriate treatment options (see page 7). Inhaled corticosteroids (ICSs) are the most effective long–term control therapy. When choosing treatment, consider domain of relevance to the patient (risk, impairment, or both), patient's history of response to the medication, and willingness and ability to use the medication. Review medications, technique, and adherence at each follow–up visit.
Patient Education for Self–Management	Teach patients how to manage their asthma. Teach and reinforce at each visit: Self–monitoring to assess level of asthma control and recognize signs of worsening asthma (either symptom or peak flow monitoring) Taking medication correctly (inhaler technique, use of devices, understanding difference between long–term control and quick–relief medications) Long–term control medications (such as inhaled corticosteroids, which reduce inflammation) prevent symptoms. Should be taken daily; will not give quick relief. Quick–relief medications (short–acting beta2–agonists or SABAs) relax airway muscles to provide fast relief of symptoms. Will not provide long–term asthma control. If used more than 2 days per week (except as needed for exercise–induced asthma), the patient may need to start or increase long–term control medications. Avoiding environmental factors that worsen asthma Develop a written asthma action plan in partnership with patient/family (sample plan available at www.nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm). Agree on treatment goals. Teach patients how to use the asthma action plan to: Take daily actions to control asthma Adjust medications in response to worsening asthma Seek medical care as appropriate Encourage adherence to the asthma action plan. Choose treatment that achieves outcomes and addresses preferences important to the patient/family. Review at each visit any success in achieving control, any concerns about treatment, any difficulties following the plan, and any possible actions to improve adherence. Provide encouragement and praise, which builds patient confidence. Encourage family involvement to provide support. Integrate education into all points of care involving interactions with patients Include members of all health care disciplines (e.g., physicians, pharmacists, nurses, respiratory therapists, and asthma educators) in providing and reinforcing education at all points of care.
Control of Environmental Factors and Comorbid Conditions	Recommend ways to control exposures to allergens, irritants, and pollutants that make asthma worse. Determine exposures, history of symptoms after exposures, and sensitivities. (In patients with persistent asthma, use skin or in vitro testing to assess sensitivity to perennial indoor allergens.) Recommend multifaceted approaches to control exposures; single steps alone are generally ineffective. Advise all asthma patients and all pregnant women to avoid exposure to tobacco smoke. Consider allergen immunotherapy by trained personnel for patients with persistent asthma when there is a clear connection between symptoms and exposure to an allergen to which the patient is sensitive. Treat comorbid conditions. Consider allergic bronchopulmonary aspergillosis, gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis and sinusitis, and stress or depression. Treatment of these conditions may improve asthma control. Consider inactivated flu vaccine for all patients more than 6 months of age.

Back to table of contents

Asthma Care for Special Circumstances

Clinical Issue	Key Clinical Activities and Action Steps
Exercise–Induced Bronchospasm (EIB)	Prevent EIB (exercise–induced bronchospasm). Physical activity should be encouraged. For most patients, EIB should not limit participation in any activity they choose. Teach patients to take treatment before exercise. SABAs (short–acting beta₂–agonist) will prevent EIB in most patients; LTRAs (leukotriene receptor antagonist), cromolyn, or LABAs (long–acting beta₂–agonist) also are protective. Frequent or chronic use of LABA to prevent EIB is discouraged, as it may disguise poorly controlled persistent asthma. Consider long–term control medication. EIB often is a marker of inadequate asthma control and responds well to regular anti–inflammatory therapy. Encourage a warm–up period or mask or scarf over the mouth for cold–induced EIB.
Pregnancy	Maintain asthma control through pregnancy. Check asthma control at all prenatal visits. Asthma can worsen or improve during pregnancy; adjust medications as needed. Treating asthma with medications is safer for the mother and fetus than having poorly controlled asthma. Maintaining lung function is important to ensure oxygen supply to the fetus. ICSs (inhaled corticosteroids) are the preferred long–term control medication. Remind patients to avoid exposure to tobacco smoke.

Clinical Issue

Key Clinical Activities and Action Steps

Exercise–Induced
Bronchospasm (EIB)

Prevent EIB (exercise–induced bronchospasm).

Physical activity should be encouraged. For most patients, EIB should not limit participation in any activity they choose.
Teach patients to take treatment before exercise. SABAs (short–acting beta₂–agonist) will prevent EIB in most patients; LTRAs (leukotriene receptor antagonist), cromolyn, or LABAs (long–acting beta₂–agonist) also are protective. Frequent or chronic use of LABA to prevent EIB is discouraged, as it may disguise poorly controlled persistent asthma.
Consider long–term control medication. EIB often is a marker of inadequate asthma control and responds well to regular anti–inflammatory therapy.
Encourage a warm–up period or mask or scarf over the mouth for cold–induced EIB.

Pregnancy

Maintain asthma control through pregnancy.

Check asthma control at all prenatal visits. Asthma can worsen or improve during pregnancy; adjust medications as needed.
Treating asthma with medications is safer for the mother and fetus than having poorly controlled asthma. Maintaining lung function is important to ensure oxygen supply to the fetus.
ICSs (inhaled corticosteroids) are the preferred long–term control medication.
Remind patients to avoid exposure to tobacco smoke.

Back to table of contents

Managing Exacerbations

Clinical Issue	Key Clinical Activities and Action Steps
Home Care	Develop a written asthma action plan (see Patient Education for Self–Management). Teach patients how to: Recognize early signs, symptoms, and peak expiratory flow (PEF) measures that indicate worsening asthma. Adjust medications (increase SABA [short–acting beta₂–agonist] and, in some cases, add oral systemic corticosteroids) and remove or withdraw from environmental factors contributing to the exacerbation. Monitor response. Seek medical care if there is serious deterioration or lack of response to treatment. Give specific instructions on who and when to call.
Urgent or Emergency Care	Assess severity by lung function measures (for ages 5 years and up), physical examination, and signs and symptoms. Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation. Use supplemental oxygen as appropriate to correct hypoxemia. Treat with repetitive or continuous SABA (short–acting beta₂–agonist), with the addition of inhaled ipratropium bromide in severe exacerbations. Give oral systemic corticosteroids in moderate or severe exacerbations or for patients who fail to respond promptly and completely to SABA. Consider adjunctive treatments, such as intravenous magnesium sulfate or heliox, in severe exacerbations unresponsive to treatment. Monitor response with repeat assessment of lung function measures, physical examination, and signs and symptoms, and, in emergency department, pulse oximetry. Discharge with medication and patient education: Medications: SABA, oral systemic corticosteroids; consider starting ICS (inhaled corticosteroids) Referral to follow–up care Asthma discharge plan Review of inhaler technique and, whenever possible, environmental control measures

Clinical Issue

Key Clinical Activities and Action Steps

Home Care

Develop a written asthma action plan (see Patient Education for Self–Management).

Teach patients how to:

Recognize early signs, symptoms, and peak expiratory flow (PEF) measures that indicate worsening asthma.
Adjust medications (increase SABA [short–acting beta₂–agonist] and, in some cases, add oral systemic corticosteroids) and remove or withdraw from environmental factors contributing to the exacerbation.
Monitor response.
Seek medical care if there is serious deterioration or lack of response to treatment. Give specific instructions on who and when to call.

Urgent or
Emergency Care

Assess severity by lung function measures (for ages 5 years and up), physical examination, and signs and symptoms.

Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation.

Use supplemental oxygen as appropriate to correct hypoxemia.
Treat with repetitive or continuous SABA (short–acting beta₂–agonist), with the addition of inhaled ipratropium bromide in severe exacerbations.
Give oral systemic corticosteroids in moderate or severe exacerbations or for patients who fail to respond promptly and completely to SABA.
Consider adjunctive treatments, such as intravenous magnesium sulfate or heliox, in severe exacerbations unresponsive to treatment.

Monitor response with repeat assessment of lung function measures, physical examination, and signs and symptoms, and, in emergency department, pulse oximetry.

Discharge with medication and patient education:

Medications: SABA, oral systemic corticosteroids; consider starting ICS (inhaled corticosteroids)
Referral to follow–up care
Asthma discharge plan
Review of inhaler technique and, whenever possible, environmental control measures

Back to table of contents

Initial Visit: Classifying Asthma Severity and Initiating Therapy (in patients who are not currently taking long–term control medications)

Level of severity (Columns 2 through 5) is determined by events listed in Column 1 for both impairment (frequency and intensity of symptoms and functional limitations) and risk (of exacerbations). Assess impairment by patient's or caregiver's recall of events during the previous 2 to 4 weeks; assess risk over the last year. Recommendations for initiating therapy based on level of severity are presented in the last row.

Note: Data are insufficient to link frequencies of exacerbations with different levels of asthma severity. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids) indicate greater underlying disease severity. For treatment purposes, patients with 2 or more exacerbations may be considered to have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Ages 0 to 4 Years
Ages 5 to 11 Years
Ages 12 Years and Older

Initial Visit: Ages 0 to 4 Years

Components of Severity	Intermittent	Persistent – Mild	Persistent – Moderate	Persistent – Severe
Impairment: Symptoms	2 days a week or less	more than 2 days a week but not daily	daily	throughout the day
Impairment: Nighttime awakenings	0	1 to 2 times a month	3 to 4 times a month	more than once a week
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasms])	2 days a week or less	more than 2 days a week, but not daily	daily	several times per day
Impairment: Interference with normal activity	none	minor limitation	some limitation	extremely limited
Impairment: Lung function: FEV₁(forced expiratory volume in one second [percent predicted])	not applicable	not applicable	not applicable	not applicable
Impairment: FEV₁/FVC (forced expiratory volume in one second divided by forced vital capacity)	not applicable	not applicable	not applicable	not applicable
Risk: Asthma exacerbations requiring oral systemic corticosteroids. Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV₁ (forced expiratory volume in one second). Generally, more frequent and intense events indicate greater severity.	0 to 1 per year	2 or more exacerbations in 6 months or wheezing 4 or more times per year lasting more than a day AND risk factors for persistent asthma	2 or more exacerbations in 6 months or wheezing 4 or more times per year lasting more than a day AND risk factors for persistent asthma	2 or more exacerbations in 6 months or wheezing 4 or more times per year lasting more than a day AND risk factors for persistent asthma
Recommended Step for Initiating Therapy (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs. In 2 to 6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed. For children 0 to 4 years old, if no clear benefit is observed in 4 to 6 weeks, consider adjusting therapy or alternate diagnoses.	Step 1	Step 2	Step 3; Consider short course of oral systemic corticosteroids	Step 3; Consider short course of oral systemic corticosteroids

Back to table of contents

Initial Visit: Ages 5 to 11 Years

Components of Severity	Intermittent	Persistent– Mild	Persistent– Moderate	Persistent– Severe
Impairment: Symptoms	2 days a week or less	more than 2 days a week but not daily	daily	throughout the day
Impairment: Nighttime awakenings	2 times a month or less	3 to 4 times a month	more than once a week, but not nightly	often 7 times a week
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasms])	2 days a week or less	more than 2 days a week, but not daily and not more than once on any day	daily	several times per day
Impairment: Interference with normal activity	none	minor limitation	some limitation	extremely limited
Impairment: Lung function: FEV₁ (forced expiratory volume in one second [percent predicted])	more than 80 percent; normal FEV₁ between exacerbations.	more than 80 percent	60 to 80 percent	less than 60 percent
Impairment: FEV₁/FVC (forced expiratory volume in one second divided by forced vital capacity)	more than 85 percent	more than 80 percent	75 to 80 percent	less than 75 percent
Risk: Asthma exacerbations requiring oral systemic corticosteroids. Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV₁ (forced expiratory volume in one second). Generally, more frequent and intense events indicate greater severity.	0 to 1 per year	2 or more per year	2 or more per year	2 or more per year
Recommended Step for Initiating Therapy (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs. In 2 to 6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.	Step 1	Step 2	Step 3, medium–dose ICS (inhaled corticosteroids) option; Consider short course of oral systemic corticosteroids	Step 3, medium–dose ICS (inhaled corticosteroids) option or step 4; Consider short course of oral systemic corticosteroids

Back to table of contents

Initial Visit: Ages 12 Years and Older

Components of Severity	Intermittent	Persistent – Mild	Persistent – Moderate	Persistent – Severe
Impairment: Symptoms	2 days a week or less	more than 2 days a week but not daily	daily	throughout the day
Impairment: Nighttime awakenings	2 times a month or less	3 to 4 times a month	more than once a week, but not nightly	often 7 times a week
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasms])	2 days a week or less	more than 2 days a week, but not daily and not more than once on any day	daily	several times per day
Impairment: Interference with normal activity	none	minor limitation	some limitation	extremely limited
Impairment: Lung function: FEV₁ (forced expiratory volume in one second [percent predicted])	more than 80 percent; normal FEV₁ between exacerbations.	more than 80 percent	60 to 80 percent	less than 60 percent
Impairment: FEV₁/FVC (forced expiratory volume in one second divided by forced vital capacity). Normal FEV₁/FVC (forced expiratory volume in one second divided by forced vital capacity) by age: 8 to 19 years, 85 percent; 20 to 39 years, 80 percent; 40 to 59 years, 75 percent; 60 to 80 years, 70 percent.	normal	normal	reduced 5 percent	reduced more than 5 percent
Risk: Asthma exacerbations requiring oral systemic corticosteroids. Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV₁ (forced expiratory volume in one second). Generally, more frequent and intense events indicate greater severity.	0 to 1 per year	2 or more per year	2 or more per year	2 or more per year
Recommended Step for Initiating Therapy (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs. In 2 to 6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.	Step 1	Step 2	Step 3; Consider short course of oral systemic corticosteroid	Step 4 or 5; Consider short course of oral systemic corticosteroid

Back to table of contents

Follow–up Visits: Assessing Asthma Control and Adjusting Therapy

Level of control (Columns 2 to 4) is based on the most severe component of impairment (symptoms and functional limitations) or risk (exacerbations). Assess impairment by patient's or caregiver's recall of events listed in Column 1 during the previous 2 to 4 weeks and by spirometry and/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. Assess risk by recall of exacerbations during the previous year and since the last visit. Recommendations for adjusting therapy based on level of control are presented in the last row.

Note: Data are insufficient to link frequencies of exacerbations with different levels of asthma control. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids) indicate poorer asthma control.

Ages 0 to 4 Years
Ages 5 to 11 Years
Ages 12 Years and Older

Follow–up Visits: Ages 0 to 4 Years

Components of Control	Well Controlled	Not Well Controlled	Very Poorly Controlled
Impairment: Symptoms	2 days a week or less	more than 2 days a week	throughout the day
Impairment: Nightime awakenings	once a month or less	more than one time a month	more than 1 time a week
Impairment: Interference with normal activity	none	some limitation	extremely limited
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasm])	2 days a week or less	more than 2 days a week	several times per day
Impairment: Lung function: FEV₁(forced expiratory volume in one second [percent predicted]) or peak flow (percent of personal best)	not applicable	not applicable	not applicable
Impairment: Lung function: FEV₁ (forced expiratory volume in one second) divided by FVC (forced vital capacity)	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ATAQ (Asthma Therapy Assessment Questionnaire©).	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ACQ (Asthma Control Questionnaire©).	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ACT (Asthma Control Test™).	not applicable	not applicable	not applicable
Risk: Asthma exacerbations requiring oral systemic corticosteroids. (Consider severity and interval since last asthma exacerbation.)	0 to 1 per year	2 to 3 per year	more than 3 per year
Risk: Reduction in lung growth/Progressive loss of lung function	Not applicable	Not applicable	Not applicable
Risk: 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.	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.	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 (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs.	Maintain current step. Regular follow–up every 1 to 6 months. Consider step down if well controlled for at least 3 months.	Step up 1 step. Reevaluate in 2 to 6 weeks to achieve control. For children 0 to 4 years, if no clear benefit observed in 4 to 6 weeks, consider adjusting therapy or alternative diagnoses. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.	Consider short course of oral systemic corticosteroids. Step up 1 to 2 steps. Reevaluate in 2 weeks to achieve control. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.

Back to table of contents

Follow–up Visits: Ages 5 to 11 Years

Components of Control	Well Controlled	Not Well Controlled	Very Poorly Controlled
Impairment: Symptoms	2 days a week or less but not more than once on each day	more than 2 days a week or multiple times on 2 or fewer days per week	throughout the day
Impairment: Nightime awakenings	once a month or less	2 times a month or more	2 times a week or more
Impairment: Interference with normal activity	none	some limitation	extremely limited
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasm])	2 days a week or less	more than 2 days per week	several times per day
Impairment: Lung function: FEV₁(forced expiratory volume in one second [percent predicted]) or peak flow (percent of personal best)	more than 80 percent	60 to 80 percent	less than 60 percent
Impairment: Lung function: FEV₁ (forced expiratory volume in one second) divided by FVC (forced vital capacity)	more than 80 percent	75 to 80 percent	less than 75 percent
Impairment: Validated questionnaires – ATAQ (Asthma Therapy Assessment Questionnaire©).	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ACQ (Asthma Control Questionnaire©).	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ACT (Asthma Control Test™).	not applicable	not applicable	not applicable
Risk: Asthma exacerbations requiring oral systemic corticosteroids. (Consider severity and interval since last asthma exacerbation.)	0 to 1 per year	2 or more per year	2 or more per year
Risk: Reduction in lung growth/Progressive loss of lung function	Evaluation requires long–term follow–up care.	Evaluation requires long–term follow–up care.	Evaluation requires long–term follow–up care.
Risk: 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.	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.	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 (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs.	Maintain current step. Regular follow–up every 1 to 6 months. Consider step down if well controlled for at least 3 months.	Step up at least 1 step. Reevaluate in 2 to 6 weeks to achieve control. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.	Consider short course of oral systemic corticosteroids. Step up 1 to 2 steps. Reevaluate in 2 weeks to achieve control. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.

Back to table of contents

Follow–up Visits: Ages 12 Years and Older

Components of Control	Well Controlled	Not Well Controlled	Very Poorly Controlled
Impairment: Symptoms	2 days a week or less	more than 2 days per week	throughout the day
Impairment: Nightime awakenings	2 times per month or less	1 to 3 times per week	4 times a week or more
Impairment: Interference with normal activity	none	some limitation	extremely limited
Impairment: SABA (short–acting beta₂–agonist) use for symptom control (not to prevent EIB [exercise–induced bronchospasm])	2 days a week or less	more than 2 days a week	several times per day
Impairment: Lung function: FEV₁(forced expiratory volume in one second [percent predicted]) or peak flow (percent of personal best)	more than 80 percent	60 to 80 percent	less than 60 percent
Impairment: Lung function: FEV₁ (forced expiratory volume in one second)/FVC (forced vital capacity)	not applicable	not applicable	not applicable
Impairment: Validated questionnaires – ATAQ (Asthma Therapy Assessment Questionnaire©). (Minimal important difference: 1.0)	0	1 to 2	3 to 4
Impairment: Validated questionnaires – ACQ (Asthma Control Questionnaire©). (Minimal important difference: 0.5)	0.75 or less (ACQ values of 0.76 to 1.4 are indeterminate regarding well–controlled asthma)	1.5 or more	not applicable
Impairment: Validated questionnaires – ACT (Asthma Control Test™). (Minimal important difference: not determined)	20 or more	16 to 19	15 or less
Risk: Asthma exacerbations requiring oral systemic corticosteroids. (Consider severity and interval since last asthma exacerbation.)	0 to 1 per year	2 or more per year	2 or more per year
Risk: Reduction in lung growth/Progressive loss of lung function	Evaluation requires long–term follow–up care.	Evaluation requires long–term follow–up care.	Evaluation requires long–term follow–up care.
Risk: 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.	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.	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 (See "Stepwise Approach for Managing Asthma Long Term") The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs.	Maintain current step. Regular follow–up every 1 to 6 months. Consider step down if well controlled for at least 3 months.	Step up 1 step. Reevaluate in 2 to 6 weeks to achieve control. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.	Consider short course of oral systemic corticosteroids. Step up 1 to 2 steps. Reevaluate in 2 weeks to achieve control. Before step up in treatment: Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used, discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.

Back to table of contents

Stepwise Approach for Managing Asthma Long Term

The stepwise approach tailors the selection of medication to the level of asthma severity (see page 5) or asthma control (see page 6).

The stepwise approach is meant to help, not replace, the clinical decision–making needed to meet individual patient needs.

Assess Control:

Step up if needed

(First, check medication adherence, inhaler technique, environmental control, and comorbid conditions)

Step down if possible

(And asthma is well controlled for at least 3 months)

At each step:

Patient education, environmental control, and management of comorbidities.

Treatment options are listed in alphabetical order, if more than one.

Ages 0 to 4 Years
Ages 5 to 11 Years
Ages 12 Years and Older

Stepwise Approach: Ages 0 to 4 Years

At each step

If clear benefit is not observed in 4 to 6 weeks, and medication technique and adherence are satisfactory, consider adjusting therapy or alternate diagnoses.

For persistent asthma (step 2 through step 6)

Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2.

	Step 1: Intermittent asthma	Step 2: Persistent Asthma: Daily Medication	Step 3: Persistent Asthma: Daily Medication	Step 4: Persistent Asthma: Daily Medication	Step 5: Persistent Asthma: Daily Medication	Step 6: Persistent Asthma: Daily Medication
Preferred Treatment	inhaled short–acting beta₂–agonist (SABA) as needed	low–dose inhaled corticosteroid (ICS)	medium–dose inhaled corticosteroid (ICS)	medium–dose inhaled corticosteroid (ICS) plus either inhaled long–acting beta₂–agonist (LABA) or montelukast	high–dose inhaled corticosteroid (ICS) plus either inhaled long–acting beta₂–agonist (LABA) or montelukast	high–dose inhaled corticosteroid (ICS) plus either inhaled long–acting beta₂–agonist (LABA) or montelukast plus oral corticosteroids
Alternative Treatment (If alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.)		cromolyn or montelukast

Guidance on Quick–Relief Medication at All Steps

Inhaled short–acting beta₂–agonist (SABA) as needed for symptoms. The intensity of treatment depends on severity of symptoms.
With viral respiratory symptoms: SABA every 4 to 6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if asthma exacerbation is severe or patient has history of severe exacerbations.
Caution: Frequent use of SABA for routine care may indicate the need to step up treatment.

Back to table of contents

Stepwise Approach: Ages 5 to 11 Years

For persistent asthma (step 2 through step 6)

Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.

Step 1: Intermittent asthma

Step 2: Persistent Asthma: Daily Medication

Step 3: Persistent Asthma: Daily Medication

Step 4: Persistent Asthma: Daily Medication

Step 5: Persistent Asthma: Daily Medication

Step 6: Persistent Asthma: Daily Medication

Preferred Treatment

Inhaled short–acting beta₂–agonist (SABA) as needed

Low–dose inhaled corticosteroid (ICS)

2 options:

Low–dose inhaled corticosteroid (ICS) plus either inhaled long–acting beta₂–agonist (LABA), leukotriene receptor antagonist (LTRA), or theophylline;
Medium–dose inhaled corticosteroid (ICS).

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

Medium–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA)

High–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA)

High–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA) plus oral corticosteroids

Alternative Treatment (If alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.)

Cromolyn, leukotriene receptor antagonist (LTRA), or theophylline.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

Medium–dose inhaled corticosteroid (ICS) plus either leukotriene receptor antagonist (LTRA) or theophylline.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

High–dose inhaled corticosteroid (ICS) plus either leukotriene receptor antagonist (LTRA) or theophylline.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

High–dose inhaled corticosteroid (ICS); plus either leukotriene receptor antagonist (LTRA) or theophylline; plus oral corticosteroids.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

Immunotherapy

Consider subcutaneous allergen immunotherapy in steps 2 through 4 for patients who have persistent, allergic asthma. This is based on evidence for house–dust mites, animal dander, and pollen; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults.

Guidance on Quick–Relief Medication at All Steps

Inhaled short–acting beta₂–agonist (SABA) as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
Caution: Increasing use of SABA or use more than 2 days per week for symptom relief (not to prevent exercise–induced bronchospasm [EIB]) generally indicates inadequate control and the need to step up treatment.

Back to table of contents

Stepwise Approach: Ages 12 Years and Older

For persistent asthma (step 2 through step 6)

Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.

Step 1: Intermittent asthma

Step 2: Persistent Asthma: Daily Medication

Step 3: Persistent Asthma: Daily Medication

Step 4: Persistent Asthma: Daily Medication

Step 5: Persistent Asthma: Daily Medication

Step 6: Persistent Asthma: Daily Medication

Preferred Treatment

Inhaled short–acting beta₂–agonist (SABA) as needed

Low–dose inhaled corticosteroid (ICS)

2 Options:

Low–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA);
Medium–dose inhaled corticosteroid (ICS)

Medium–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA)

High–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA) AND consider omalizumab for patients who have allergies.

Note: Clinicians who administer immunotherapy or omalizumab should be prepared to treat anaphylaxis that may occur.

High–dose inhaled corticosteroid (ICS) plus inhaled long–acting beta₂–agonist (LABA) plus oral corticosteroids AND consider omalizumab for patients who have allergies.

Note: Before oral corticosteroids are introduced, a trial of high–dose ICS plus LABA plus either LTRA, theophyline, or zileuton, may be considered, although this approach has not been studied in clinical trials. Clinicians who administer immunotherapy or omalizumab should be prepared to treat anaphylaxis that may occur.

Alternative Treatment (If alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.)

Cromolyn, leukotriene receptor antagonist (LTRA), or theophylline.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels.

Low–dose inhaled corticosteroid (ICS) plus either leukotriene receptor antagonist (LTRA), theophylline, or zileuton.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels. Zileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.

Medium–dose inhaled corticosteroid (ICS) plus either leukotriene receptor antagonist (LTRA), theophylline, or zileuton.

Note: Theophylline is a less desirable alternative because of the need to monitor serum concentrations levels. Zileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.

Immunotherapy

Guidance on Quick–Relief Medication at All Steps

Inhaled short–acting beta₂–agonist (SABA) as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
Caution: Use of SABA more than 2 days per week for symptom relief (not to prevent exercise–induced bronchospasm [EIB]) generally indicates inadequate control and the need to step up treatment.

Back to table of contents

Estimated Comparative Daily Doses: Inhaled Corticosteroids for Long–Term Asthma Control

Abbreviations:

DPI: dry powder inhaler (requires deep, fast inhalation)

MDI: metered dose inhaler (releases a puff of medication)

It is preferable to use a higher microgram per puff or microgram per inhalation formulation to achieve as low a number of puffs or inhalations as possible.

Ages 0 to 4 Years
Ages 5 to 11 Years
Ages 12 Years and Older

Estimated Comparative Daily Doses: Ages 0 to 4 Years

Medication – Daily Dose	Low	Medium	High
Beclomethasone MDI	not applicable	not applicable	not applicable
Budesonide DPI	not applicable	not applicable	not applicable
Budesonide Nebules	0.25 to 0.5 millligrams	more than 0.5 to 1.0 milligram	more than 1.0 milligram
0.25 milligram	1 to 2 nebules per day
0.5 milligram	1 nebule per day	2 nebules per day	3 nebules per day
1.0 milligram		1 nebule per day	2 nebules per day
Ciclesonide MDI	not applicable	not applicable	not applicable
Flunisolide MDI	not applicable	not applicable	not applicable
Fluticasone MDI	176 micrograms	more than 176 to 352 micrograms	more than 352 micrograms
44 micrograms per puff	2 puffs twice a day	3 to 4 puffs twice a day
110 micrograms per puff		1 puff twice a day	2 or more puffs twice a day
Fluticasone DPI	not applicable	not applicable	not applicable
Mometasone DPI	not applicable	not applicable	not applicable

Back to table of contents

Estimated Comparative Daily Doses: Ages 5 to 11 Years

Medication – Daily Dose	Low	Medium	High
Beclomethasone MDI	80 to 160 micrograms	more than 160 to 320 micrograms	more than 320 micrograms
40 micrograms per puff	1 to 2 puffs twice a day	3 to 4 puffs twice aday
80 micrograms per puff	1 puff twice a day	2 puffs twice a day	3 or more puffs twice a day
Budesonide DPI	180 to 360 micrograms	more than 360 to 720 micrograms	more than 720 micrograms
90 micrograms per inhalation	1 to 2 inhalations twice a day	3 to 4 inhalations twice a day
180 micrograms per inhalation		2 inhalations twice a day	3 or more inhalations twice a day
Budesonide Nebules	0.5 milligram	1.0 milligram	2.0 milligrams
0.25 milligram	1 nebule twice a day
0.5 milligram	1 nebule per day	1 nebule twice a day
1.0 milligram		1 nebule per day	1 nebule twice a day
Ciclesonide MDI	80 to 160 micrograms	more than 160 to 320 micrograms	more than 320 micrograms
80 micrograms per puff	1 to 2 puffs per day	1 puff a.m., 2 puffs p.m. to 2 puffs twice a day	3 or more puffs twice a day
160 micrograms per puff	1 puff per day	1 puff twice a day	2 or more puffs twice a day
Flunisolide MDI	160 micrograms	320 to 480 micrograms	480 or more micrograms
80 micrograms per puff	1 puff twice a day	2 to 3 puffs twice a day	4 or more puffs twice a day
Fluticasone MDI	88 to 176 micrograms	more than 176 to 352 micrograms	more than 352 micrograms
44 micrograms per puff	1 to 2 puffs twice a day	3 to 4 puffs twice a day
110 micrograms per puff		1 puff twice a day	2 or more puffs twice a day
220 micrograms per puff
Fluticasone DPI	100 to 200 micrograms	more than 200 to 400 micrograms	more than 400 micrograms
50 micrograms per inhalation	1 to 2 inhalations twice a day	3 to 4 inhalations twice a day
100 micrograms per inhalation	1 inhalation twice a day	2 inhalations twice a day	more than 2 inhalations twice a day
250 micrograms per inhalation			1 inhalation twice a day
Mometasone DPI	110 micrograms	220 to 440 micrograms	more than 440 micrograms
110 micrograms per inhalation	1 inhalation per day	1 to 2 inhalations twice a day	3 or more inhalations twice a day
220 micrograms per inhalation		1 to 2 inhalations a day	3 or more inhalations divided in 2 doses

Back to table of contents

Estimated Comparative Daily Doses: Ages 12 Years and Older

Medication – Daily Dose	Low	Medium	High
Beclomethasone MDI	80 to 240 micrograms	more than 240 to 480 micrograms	more than 480 micrograms
40 micrograms per puff	1 to 3 puffs twice a day	4 to 6 puffs twice a day
80 micrograms per puff	1 puff a.m., 2 puffs p.m.	2 to 3 puffs twice a day	4 or more puffs twice a day
Budesonide DPI	180 to 540 micrograms	more than 540 to 1,080 micrograms	more than 1,080 micrograms
90 micrograms per inhalation	1 to 3 inhalations twice a day
180 micrograms per inhalation	1 inhalation a.m., 2 inhalations p.m.	2 to 3 inhalations twice a day	4 or more inhalations twice a day
Budesonide Nebules	not applicable	not applicable	not applicable
0.25 mg	not applicable	not applicable	not applicable
0.5 mg	not applicable	not applicable	not applicable
1.0 mg	not applicable	not applicable	not applicable
Ciclesonide MDI	160 to 320 micrograms	more than 320 to 640 micrograms	more than 640 micrograms
80 micrograms per puff	1 to 2 puffs twice a day	3 to 4 puffs twice a day
160 micrograms per puff		2 puffs twice a day	3 or more puffs twice a day
Flunisolide MDI	320 micrograms	more than 320 to 640 micrograms	more than 640 micrograms
80 micrograms per puff	2 puffs twice a day	3 to 4 puffs twice a day	5 puffs or more twice a day
Fluticasone MDI	88 to 264 micrograms	more than 264 to 440 micrograms	more than 440 micrograms
44 micrograms per puff	1 to 3 puffs twice a day
110 micrograms per puff		2 puffs twice a day	3 puffs twice a day
220 micrograms per puff		1 puff twice a day	2 or more puffs twice a day
Fluticasone DPI	100 to 300 micrograms	more than 300 to 500 micrograms	more than 500 micrograms
50 micrograms per inhalation	1 to 3 inhalations twice a day
100 micrograms per inhalation		2 inhalations twice a day	3 or more inhalations twice a day
250 micrograms per inhalation		1 inhalations twice a day	2 or more inhalations twice a day
Mometasone DPI	110 to 220 micrograms	more than 220 to 440 micrograms	more than 440 micrograms
110 micrograms per inhalation	1 to 2 inhalations p.m.	3 to 4 inhalations p.m. or 2 inhalations twice a day	3 or more inhalations twice a day
220 micrograms per inhalation	1 inhalation p.m.	1 inhalation twice a day or 2 inhalations p.m.	3 or more inhalations divided in two doses

Back to table of contents

Therapeutic Issues Pertaining to Inhaled Corticosteroids (ICS) for Long–Term Asthma Control

The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response on several clinical parameters (e.g., symptoms; activity level; measures of lung function) and adjust the dose accordingly. Once asthma control is achieved and sustained at least 3 months, the dose should be carefully titrated down to the minimum dose necessary to maintain control.
Some doses may be outside package labeling, especially in the high–dose range. Budesonide nebulizer suspension is the only inhaled corticosteroid (ICS) with FDA–approved labeling for children less than 4 years of age.
Metered–dose inhaler (MDI) dosages are expressed as the actuator dose (amount leaving the actuator and delivered to the patient), which is the labeling required in the U.S. This is different from the dosage expressed as the valve dose (amount of drug leaving the valve, not all of which is available to the patient), which is used in many European countries and in some scientific literature. Dry powder inhaler (DPI) doses are expressed as the amount of drug in the inhaler following activation.
For children less than 4 years of age: The safety and efficacy of ICSs in children under 1 year of age has not been established. Children less than 4 years of age generally require delivery of ICS (budesonide and fluticasone MDI) through a face mask that fits snugly over nose and mouth to avoid nebulizing in the eyes. Face should be washed after treatment to prevent local corticosteroid side effects. For budesonide, the dose may be given 1 to 3 times daily. Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer. Use only jet nebulizers, as ultrasonic nebulizers are ineffective for suspensions. For fluticasone MDI, the dose should be divided 2 times daily; the low dose for children less than 4 years of age is higher than for children 5 to 11 years of age because of lower dose delivered with face mask and data on efficacy in young children.

Back to Table of Contents

Usual Dosages for Other Long–Term Control Medications

Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use.

Abbreviations

IgE: immunoglobulin E

N/A: not available (not aproved, no data available, or safety and efficacy not established for this age group).

Ages 0 to 4 Years
Ages 5 to 11 Years
Ages 12 years and Older

Usual Dosages for Other Long–Term Control Medications: Ages 0 to 4 Years

Medication	Dosages
Combined Medication (inhaled corticosteroid + long–acting beta₂–agonist)
Fluticasone/Salmeterol Dry powder inhaler (DPI) 100 micrograms/50 micrograms, 250 micrograms/50 micrograms, or 500 micrograms/50 micrograms Metered–dose inhaler (MDI) 45 micrograms/21 micrograms, 115 micrograms/21 micrograms, or 230 micrograms/21 micrograms	N/A
Budesonide/Formoterol Metered–dose inhaler (MDI): 80 micrograms/4.5 micrograms or 160 micrograms/4.5 micrograms	N/A
Mometasone/Formoterol Metered–dose inhaler (MDI): 100 micrograms/5 micrograms	N/A
Leukotriene Modifiers
Leukotriene Receptor Antagonists (LTRAs) Montelukast 4 milligrams or 5 milligrams chewable tablet, 4 milligram granule packets, 10 milligram tablet	4 milligrams every night at bedtime (1 to 5 years of age)
Zafirlukast 10 milligram or 20 milligram tablet. Take at least 1 hour before or 2 hours after a meal. Monitor liver function.	N/A
5–Lipoxygenase Inhibitor Zileuton 600 milligram tablet. Monitor liver function.	N/A
Immunomodulators
Omalizumab (Anti Immunoglobulin E) Subcutaneous injection, 150 milligrams/1.2 milliliter following reconstitution with 1.4 milliliter sterile water for injection. Monitor patients after injections; be prepared to treat anaphylaxis that may occur.	N/A
Cromolyn
Cromolyn Nebulizer: 20 milligrams per ampule	1 ampule 4 times a day, N/A less than 2 years of age
Methylxanthines
Theophylline Liquids, sustained–release tablets, and capsules. Monitor serum concentration levels.	Starting dose 10 milligrams per kilogram per day; usual maximum: less than 1 year of age: 0.2 times age in weeks + 5 = milligrams per kilogram per day 1 year of age or more: 16 milligrams per kilogram per day
Inhaled Long–Acting Beta₂–Agonists (LABAs) – used in conjunction with ICS (inhaled corticosteroids) for long–term control; LABA is NOT to be used as monotherapy
Salmeterol Dry powder inhaler (DPI): 50 micrograms per blister	N/A
Formoterol Dry powder inhaler (DPI): 12 micrograms per single–use capsule	N/A
Oral Systemic Corticosteroids
Methylprednisolone 2, 4, 8, 16, 32 milligram tablets Prednisolone 5 milligram tablets; 5 milligram/5 cubic centimeters, 15 milligram/5 cubic centimeters Prednisone 1, 2.5, 5, 10, 20, 50 milligram tablets; 5 milligram/cubic centimeter, 5 milligram/5 cubic centimeter	0.25 to 2 milligrams per kilogram daily in single dose in a.m. or every other day as needed for control Short course "burst": 1 to 2 milligrams per kilogram per day, max 60 milligrams per day for 3 to 10 days

Back to table of contents

Usual Dosages for Other Long–Term Control Medications: Ages 5 to 11 Years

Medication	Dosages
Combined Medication (inhaled corticosteroid + long–acting beta₂–agonist)
Fluticasone/Salmeterol Dry powder inhaler (DPI) 100 micrograms/50 micrograms, 250 micrograms/50 micrograms, or 500 micrograms/50 micrograms Metered–dose inhaler (MDI) 45 micrograms/21 micrograms, 115 micrograms/21 micrograms, or 230 micrograms/21 micrograms	1 inhalation, twice a day; dose depends on level of severity or control
Budesonide/Formoterol Metered–dose inhaler (MDI): 80 micrograms/4.5 micrograms or 160 micrograms/4.5 micrograms	2 puffs twice a day; dose depends on level of severity or control
Mometasone/Formoterol Metered–dose inhaler (MDI): 100 micrograms/5 micrograms	N/A
Leukotriene Modifiers
Leukotriene Receptor Antagonists (LTRAs) Montelukast 4 milligram or 5 milligram chewable tablet, 4 milligram granule packets, 10 milligram tablet	5 milligrams every night at bedtime (6 to 14 years of age)
Zafirlukast 10 milligram or 20 milligram tablet Take at least 1 hour before or 2 hours after a meal. Monitor liver function.	10 milligrams twice a day (7 to 11 years of age)
5–Lipoxygenase Inhibitor Zileuton 600 milligram tablet. Monitor liver function.	N/A
Immunomodulators
Omalizumab (Anti Immunoglobulin E) Subcutaneous injection, 150 milligrams/1.2 milliliters following reconstitution with 1.4 milliliters sterile water for injection. Monitor patients after injections; be prepared to treat anaphylaxis that may occur.	N/A
Cromolyn
Cromolyn Nebulizer: 20 milligram/ampule	1 ampule 4 times per day
Methylxanthines
Theophylline Liquids, sustained–release tablets, and capsules Monitor serum concentration levels.	Starting dose 10 milligrams per kilogram per day; usual maximum: 16 milligrams per kilogram per day
Inhaled Long–Acting Beta₂–Agonists (LABAs) – used in conjunction with ICS for long–term control; LABA is NOT to be used as monotherapy
Salmeterol Dry powder inhaler (DPI): 50 micrograms per blister	1 blister every 12 hours
Formoterol Dry powder inhaler (DPI): 12 micrograms per single–use capsule	1 capsule every 12 hours
Oral Systemic Corticosteroids
Methylprednisolone 2, 4, 8, 16, 32 milligram tablets Prednisolone 5 milligram tablets; 5 milligram/5 cubic centimeters, 15 milligram/5 cubic centimeters Prednisone 1, 2.5, 5, 10, 20, 50 milligram tablets; 5 milligrams/cubic centimeter, 5 milligrams/5 cubic centimeters	0.25 to 2 milligrams per kilogram daily in single dose in a.m. or every other day as needed for control Short course "burst": 1 to 2 milligrams per kilogram per day, max 60 milligrams per day for 3 to 10 days

Back to table of contents

Usual Dosages for Other Long–Term Control Medications: Ages 12 and Older

Medication	Dosages
Combined Medication (inhaled corticosteroid plus long–acting beta₂–agonist)
Fluticasone/Salmeterol Dry powder inhaler (DPI) 100 micrograms/50 micrograms, 250 micrograms/50 micrograms, or 500 micrograms/50 micrograms Metered–dose inhaler (MDI) 45 micrograms/21 micrograms, 115 micrograms/21 micrograms, or 230 micrograms/21 micrograms	1 inhalation twice a day; dose depends on level of severity or control
Budesonide/Formoterol Metered–dose inhaler (MDI): 80 micrograms/4.5 micrograms or 160 micrograms/4.5 micrograms	2 puffs twice a day; dose depends on level of severity or control
Mometasone/Formoterol Metered–dose inhaler (MDI): 100 micrograms/5 micrograms	2 inhalations twice day; dose depends on severity of asthma
Leukotriene Modifiers
Leukotriene Receptor Antagonists (LTRAs) Montelukast 4 milligram or 5 milligram chewable tablet, 4 milligram granule packets, 10 milligram tablet	10 milligrams every night at bedtime
Zafirlukast 10 milligram or 20 milligram tablet. Take at least 1 hour before or 2 hours after a meal. Monitor liver function.	40 milligrams daily (20 milligram tablet twice a day)
5–Lipoxygenase Inhibitor Zileuton 600 milligram tablet Monitor liver function.	2,400 milligrams daily (give 1 tablet 4 times per day)
Immunomodulators
Omalizumab (Anti Immunoglobulin E) Subcutaneous injection, 150 milligrams/1.2 milliliters following reconstitution with 1.4 milliliters sterile water for injection. Monitor patients after injections; be prepared to treat anaphylaxis that may occur.	150 to 375 milligrams subcutaneous every 2 to 4 weeks, depending on body weight and pretreatment serum immunoglobulin E level
Cromolyn
Cromolyn Nebulizer: 20 milligrams/ampule	1 ampule 4 times per day
Methylxanthines
Theophylline Liquids, sustained–release tablets, and capsules Monitor serum concentration levels.	Starting dose 10 milligrams per kilogram per day up to 300 milligrams maximum; usual maximum: 800 milligrams per day
Inhaled Long–Acting Beta₂–Agonists (LABAs) used in conjunction with ICS for long–term control; LABA is NOT to be used as monotherapy
Salmeterol Dry powder inhaler (DPI): 50 micrograms/blister	1 blister every 12 hours
Formoterol Dry powder inhaler (DPI): 12 micrograms/single–use capsule	1 capsule every 12 hours
Oral Systemic Corticosteroids
Methylprednisolone 2, 4, 8, 16, 32 milligram tablets Prednisolone 5 milligram tablets; 5 milligrams/5 cubic centimeters, 15 milligrams/5 cubic centimeters Prednisone 1, 2.5, 5, 10, 20, 50 milligram tablets; 5 milligrams/cubic centimeter, 5 milligrams/5 cubic centimeters	7.5 to 60 milligrams daily in single dose in a.m. or every other day as needed for control Short course "burst": to achieve control, 40 to 60 milligrams per day as single or 2 divided doses for 3 to 10 days

The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response on several clinical parameters (e.g., symptoms; activity level; measures of lung function) and adjust the dose accordingly. Once asthma control is achieved and sustained at least 3 months, the dose should be carefully titrated down to the minimum dose necessary to maintain control.

Back to table of contents

Responding to Patient Questions about Inhaled Corticosteroids

Questions and varying beliefs about inhaled corticosteroids (ICSs) are common and may affect adherence to treatment. Following are some key points to share with patients and families.

ICSs are the most effective medications for long–term control of persistent asthma. Because ICSs are inhaled, they go right to the lungs to reduce chronic airway inflammation. In general, ICSs should be taken every day to prevent asthma symptoms and attacks.
The potential risks of ICSs are well balanced by their benefits. To reduce the risk of side effects, patients should work with their doctor to use the lowest dose that maintains asthma control, and be sure to take the medication correctly.
- Mouth irritation and thrush (yeast infection), which may be associated with ICSs at higher doses, can be avoided by rinsing the mouth and spitting after ICS use and, if appropriate for the inhaler device, by using a valved holding chamber or spacer.
- ICS use may slow a child's growth rate slightly. This effect on linear growth is not predictable and is generally small (about 1 cm), appears to occur in the first several months of treatment, and is not progressive. The clinical significance of this potential effect has yet to be determined. Growth rates are highly variable in children, and poorly controlled asthma can slow a child's growth.
ICSs are generally safe for pregnant women. Controlling asthma is important for pregnant women to be sure the fetus receives enough oxygen.
ICSs are not addictive.
ICSs are not the same as anabolic steroids that some athletes use illegally to increase sports performance.

Back to table of contents

Responding to Patient Questions about Long–Acting Beta₂–Agonists

Keep the following key points in mind when educating patients and families about long–acting beta₂–agonists (LABAs).

The addition of LABA (salmeterol or formoterol) to the treatment of patients who require more than low–dose inhaled corticosteroid (ICS) alone to control asthma improves lung function, decreases symptoms, and reduces exacerbations and use of short–acting beta₂–agonists (SABA) for quick relief in most patients to a greater extent than doubling the dose of ICS.
A large clinical trial found that slightly more deaths occurred in patients taking salmeterol in a single inhaler every day in addition to usual asthma therapy (13 out of about 13,000) compared with patients taking a placebo in addition to usual asthma therapy (3 out of about 13,000). (Note: Usual therapy included a wide range of regimens, from those in which no other daily therapy was taken to those in which varying doses of other daily medications were taken.) Trials for formoterol in a single inhaler every day in addition to usual therapy found more severe asthma exacerbations in patients taking formoterol, especially at higher doses, compared with those taking a placebo added to usual therapy. Therefore, the Food and Drug Administration placed a Black Box warning on all drugs containing a LABA.
The established benefits of LABAs added to ICS for the great majority of patients who require more than low–dose ICS alone to control asthma should be weighed against the risk of severe exacerbations, although uncommon, associated with daily use of LABAs.
LABAs should not be used as monotherapy for long–term control. Even though symptoms may improve significantly, it is important to keep taking ICS while taking LABA.
Daily use should generally not exceed 100 micrograms salmeterol or 24 micrograms formoterol.
It is not currently recommended that LABAs be used to treat acute symptoms or exacerbations.

Back to table of contents

Educational Resources

National Heart, Lung, and Blood Institute

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR–3) http://www.nhlbi.nih.gov/guidelines/asthma
Physician Asthma Care Education (PACE): http://www.nhlbi.nih.gov/health/prof/lung/asthma/pace/
National Asthma Control Initiative (NACI): http://naci.nhlbi.nih.gov

American Lung Association

800–LUNG–USA (800–586–4872)
http://www.lungusa.org

American School Health Association

800–445–2742
http://www.ashaweb.org

Asthma and Allergy Foundation of America

800–7–ASTHMA (800–727–8462)
http://aafa.org

Centers for Disease Control and Prevention

800–CDC–INFO (800–232–4636)
http://www.cdc.gov/asthma

Environmental Protection Agency/
Asthma Community Network

http://www.asthmacommunitynetwork.org
800–490–9198 (to order EPA publications)
http://www.epa.gov/asthma/publications.html

National Association of School Nurses

240–821–1130
http://www.nasn.org

For more information contact:

NHLBI Information Center

P.O. Box 30105
Bethesda, MD 20824–0105
Phone: 301–592–8573
Fax: 301–592–8563
Web site: http://www.nhlbi.nih.gov

NHLBI Publication No. 12–5075
Originally Printed June 2002
Revised September 2012

Back to table of contents

Asthma Care Quick Reference: Diagnosing and Managing Asthma

Table of Contents

Introduction

Initial Visit

Follow–up Visits

Key Clinical Activities for Quality Asthma Care

Asthma Diagnosis

Establish asthma diagnosis

Long–term Asthma Management

GOAL: Asthma Control

Reduce Impairment

Reduce Risk

Assessment and Monitoring

INITIAL VISIT: Assess asthma severity to initiate treatment (see page 5).

FOLLOW–UP VISITS: Assess asthma control to determine if therapy should be adjusted (see page 6).

Schedule follow–up care

Asthma is highly variable over time. See patients:

Use of Medications

Select medication and delivery devices that meet patient's needs and circumstances.

Review medications, technique, and adherence at each follow–up visit.

Patient Education for Self–Management

Teach patients how to manage their asthma.

Teach and reinforce at each visit:

Develop a written asthma action plan in partnership with patient/family (sample plan available at www.nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm).

Integrate education into all points of care involving interactions with patients

Control of Environmental Factors and Comorbid Conditions

Recommend ways to control exposures to allergens, irritants, and pollutants that make asthma worse.

Determine exposures, history of symptoms after exposures, and sensitivities. (In patients with persistent asthma, use skin or in vitro testing to assess sensitivity to perennial indoor allergens.)

Treat comorbid conditions.

Asthma Care for Special Circumstances

Exercise–Induced Bronchospasm (EIB)

Prevent EIB (exercise–induced bronchospasm).

Pregnancy

Maintain asthma control through pregnancy.

Managing Exacerbations

Home Care

Develop a written asthma action plan (see Patient Education for Self–Management).

Teach patients how to:

Urgent or Emergency Care

Assess severity by lung function measures (for ages 5 years and up), physical examination, and signs and symptoms.

Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation.

Monitor response with repeat assessment of lung function measures, physical examination, and signs and symptoms, and, in emergency department, pulse oximetry.

Discharge with medication and patient education:

Initial Visit: Classifying Asthma Severity and Initiating Therapy (in patients who are not currently taking long–term control medications)

Initial Visit: Ages 0 to 4 Years

Initial Visit: Ages 5 to 11 Years

Initial Visit: Ages 12 Years and Older

Follow–up Visits: Assessing Asthma Control and Adjusting Therapy

Follow–up Visits: Ages 0 to 4 Years

Follow–up Visits: Ages 5 to 11 Years

Follow–up Visits: Ages 12 Years and Older

Stepwise Approach for Managing Asthma Long Term

Assess Control:

Step up if needed

Step down if possible

At each step:

Stepwise Approach: Ages 0 to 4 Years

At each step

For persistent asthma (step 2 through step 6)

Guidance on Quick–Relief Medication at All Steps

Stepwise Approach: Ages 5 to 11 Years

For persistent asthma (step 2 through step 6)

Immunotherapy

Guidance on Quick–Relief Medication at All Steps

Stepwise Approach: Ages 12 Years and Older

For persistent asthma (step 2 through step 6)

Immunotherapy

Guidance on Quick–Relief Medication at All Steps

Estimated Comparative Daily Doses: Inhaled Corticosteroids for Long–Term Asthma Control

Abbreviations:

Estimated Comparative Daily Doses: Ages 0 to 4 Years

Beclomethasone MDI

Budesonide DPI

Budesonide Nebules

Ciclesonide MDI

Flunisolide MDI

Fluticasone MDI

Fluticasone DPI

Mometasone DPI

Estimated Comparative Daily Doses: Ages 5 to 11 Years

FOLLOW–UP VISITS: Assess asthma control to determine if therapy should be adjusted
(see page 6).

Exercise–Induced
Bronchospasm (EIB)

Urgent or
Emergency Care

Combined Medication (inhaled corticosteroid + long–acting beta₂–agonist)

Inhaled Long–Acting Beta₂–Agonists (LABAs) –

Combined Medication (inhaled corticosteroid + long–acting beta₂–agonist)

Inhaled Long–Acting Beta₂–Agonists (LABAs)