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Guidelines from the National Asthma Education
and Prevention Program
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.
The diagram (right) illustrates the steps involved in providing
quality asthma care.
INITIAL VISIT
Diagnose asthma
Schedule follow-up appointment
Develop written asthma action plan
Initiate medication & demonstrate use
Assess asthma severity
Assess & monitor
asthma control
Schedule next
follow-up
appointment
Review asthma
action plan, revise
as needed Maintain, step
up, or step down
medication
Review medication
technique &
adherence; assess
side effects; review
environmental control
FOLLOW-UP VISITS
EXPERT PANEL REPORT 3
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 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.
Asthma Care
Quick Reference
DIAGNOSING AND MANAGING ASTHMA
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Guidelines from the National Asthma Education

and Prevention Program

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.

The diagram (right) illustrates the steps involved in providing

quality asthma care.

INITIAL VISIT

Diagnose asthma

Schedule follow-up appointment

Develop written asthma action plan

Initiate medication & demonstrate use

Assess asthma severity

Assess & monitor

asthma control

Schedule next

follow-up

appointment

Review asthma

action plan, revise

as needed

Maintain, step

up, or step down

medication

Review medication

technique &

adherence; assess

side effects; review

environmental control

FOLLOW-UP VISITS

EXPERT PANEL REPORT 3

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 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.

Asthma Care

Quick Reference

DIAGNOSING AND MANAGING ASTHMA

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.

ƒ ƒ 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

ƒ ƒ In all patients ≥5 years of age, use spirometry to determine that airway obstruction is at

least partially reversible.

ƒ ƒ Consider other causes of obstruction.

LONG-TERM ASTHMA MANAGEMENT

GOAL:

Asthma Control

Reduce Impairment

ƒ ƒ Prevent chronic symptoms.

ƒ ƒ Require infrequent use of short-acting beta

2

-agonist (SABA).

ƒ ƒ Maintain (near) normal lung function and normal activity levels.

Reduce Risk

ƒ ƒ Prevent exacerbations.

ƒ ƒ Minimize need for emergency care, hospitalization.

ƒ ƒ Prevent loss of lung function (or, for children, prevent reduced lung growth).

ƒ ƒ 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).

ƒ ƒ Assess at each visit: asthma control, proper medication technique, written asthma action

plan, patient adherence, patient concerns.

ƒ ƒ Obtain lung function measures by spirometry at least every 1–2 years; more frequently for

asthma that is not well controlled.

ƒ ƒ Determine if therapy should be adjusted: Maintain treatment; step up, if needed; step

down, if possible.

Schedule follow-up care.

ƒ ƒ Asthma is highly variable over time. See patients:

  • Every 2–6 weeks while gaining control
  • Every 1–6 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.

ƒ ƒ Use stepwise approach to identify appropriate treatment options (see page 7).

ƒ ƒ Inhaled corticosteroids (ICSs) are the most effective long-term control therapy.

ƒ ƒ 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.

ASTHMA CARE FOR SPECIAL CIRCUMSTANCES

Clinical Issue Key Clinical Activities and Action Steps

Exercise-Induced

Bronchospasm

Prevent EIB. *

ƒ ƒ Physical activity should be encouraged. For most patients, EIB should not limit

participation in any activity they choose.

ƒ ƒ Teach patients to take treatment before exercise. SABAs* will prevent EIB in most patients;

LTRAs,* cromolyn, or LABAs* also are protective. Frequent or chronic use of LABA to

prevent EIB is discouraged, as it may disguise poorly controlled persistent asthma.

ƒ ƒ Consider long-term control medication. EIB often is a marker of inadequate asthma control

and responds well to regular anti-inflammatory therapy.

ƒ ƒ Encourage a warm-up period or mask or scarf over the mouth for cold-induced EIB.

Pregnancy Maintain asthma control through pregnancy.

ƒ ƒ Check asthma control at all prenatal visits. Asthma can worsen or improve during

pregnancy; adjust medications as needed.

ƒ ƒ 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.

ƒ ƒ ICSs* are the preferred long-term control medication.

ƒ ƒ Remind patients to avoid exposure to tobacco smoke.

MANAGING EXACERBATIONS

Clinical Issue Key Clinical Activities and Action Steps

Home Care

Develop a written asthma action plan (see Patient Education for Self-Management, page 3).

Teach patients how to:

ƒ ƒ Recognize early signs, symptoms, and PEF* measures that indicate worsening asthma.

ƒ ƒ Adjust medications (increase SABA* and, in some cases, add oral systemic corticosteroids)

and remove or withdraw from environmental factors contributing to the exacerbation.

ƒ ƒ Monitor response.

ƒ ƒ 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), physical examination, and

signs and symptoms.

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

ƒ ƒ Use supplemental oxygen as appropriate to correct hypoxemia.

ƒ ƒ Treat with repetitive or continuous SABA,* with the addition of inhaled ipratropium

bromide in severe exacerbations.

ƒ ƒ Give oral systemic corticosteroids in moderate or severe exacerbations or for patients who

fail to respond promptly and completely to SABA.

ƒ ƒ 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:

ƒ ƒ Medications: SABA, oral systemic corticosteroids; consider starting ICS*

ƒ ƒ Referral to follow-up care

ƒ ƒ Asthma discharge plan

ƒ ƒ Review of inhaler technique and, whenever possible, environmental control measures

Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting beta

2

-agonist; LTRA, leukotriene receptor

antagonist; PEF, peak expiratory flow; SABA, short-acting beta 2

-agonist.

INITIAL VISIT:

CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY

(in patients who are not currently taking long-term control medications) Level of severity (Columns 2–5) 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 2–4 weeks; assess risk over the last year. Recommendations for initiating therapy based on level of severity are presented in the last row.

Components of

Severity

Intermittent

Persistent

Mild

Moderate

Severe

Ages

0–4 years

Ages

5–11 years

Ages

12 years

Ages

0–4 years

Ages

5–11 years

Ages

12 years

Ages

0–4 years

Ages

5–11 years

Ages

12 years

Ages

0–4 years

Ages

5–11 years

Ages

12 years

Impairment

Symptoms

2 days/week

2 days/week but not daily

Daily

Throughout the day

Nighttime awakenings

2x/month

1–2x/month

3–4x/month

3–4x/month

1x/week but not nightly

1x/week

Often 7x/week

SABA

use for

symptom control (not to prevent EIB

2 days/week

2 days/week

but not daily

2 days/week but

not daily and not more

than once on any day

Daily

Several times per day

Interference with normal activity

None

Minor limitation

Some limitation

Extremely limited

Lung function

FEV

1

(% predicted)

FEV

1

/FVC

Not

applicable

Normal FEV

1

between

exacerbations

Normal FEV

1

between

exacerbations

Normal

Not

applicable

Normal

Not

applicable

Reduced 5%

Not

applicable

Reduced >5%

Risk

Asthma exacerbations requiring oral systemic corticosteroids

0–1/year

2 exacerb.

in 6 months, or wheezing

4x

per

year lasting

1 day

AND risk

factors for persistent

asthma

2/year

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 FEV

1

Recommended Step for Initiating Therapy (See “Stepwise Approach for Managing Asthma Long Term,” page 7) The stepwise approach is meant to help, not replace, the clinical decisionmaking needed to meet individual patient needs.

Step 1

Step 2

Step 3

Step 3

medium-dose

ICS

option

Step 3

Step 3

Step 3

medium-dose

ICS

option

or Step 4

Step 4

or 5

Consider short course of oral systemic corticosteroids.

In 2–6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.

For children 0–4 years old, if no clear benefit is observed in 4–6 weeks, consider adjusting therapy or alternate diagnoses.

Abbreviations:

EIB, exercise-induced bronchospam; FEV

1

, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting beta

2

-agonist.

Normal FEV

1

/FVC by age: 8–19 years, 85%; 20–39 years, 80%; 40–59 years, 75%; 60–80 years, 70%.

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 exacerbations may be considered to have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Generally, more frequent and intense events indicate greater severity.

Generally, more frequent and intense events indicate greater severity.

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 decisionmaking needed to meet individual patient needs.

At each step: Patient education, environmental control, and management of comorbidities

0–4 years of age

Intermittent

Asthma

Persistent Asthma: Daily Medication

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

Preferred

Treatment

SABA as

needed

low-dose ICS medium-dose

ICS

medium-dose

ICS

either LABA or

montelukast

high-dose ICS

either LABA or

montelukast

high-dose ICS

either LABA or

montelukast

oral corticosteroids

Alternative

Treatment

,

cromolyn or

montelukast

If clear benefit is not observed in 4–6 weeks, and medication technique and adherence are satisfactory,

consider adjusting therapy or alternate diagnoses.

Quick-Relief

Medication

ƒ ƒ SABA as needed for symptoms; intensity of treatment depends on severity of symptoms.

ƒ ƒ With viral respiratory symptoms: SABA every 4–6 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.

ƒ ƒ Caution: Frequent use of SABA may indicate the need to step up treatment.

5–11 years of age

Intermittent

Asthma

Persistent Asthma: Daily Medication

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

Preferred

Treatment

SABA as needed low-dose ICS low-dose ICS

either LABA,

LTRA, or

theophylline

(b)

OR

medium-dose

ICS

medium-dose

ICS
LABA

high-dose ICS

LABA

high-dose ICS

LABA

oral corticosteroids

Alternative

Treatment

,

cromolyn, LTRA,

or theophylline

§

medium-dose ICS

either LTRA or

theophylline

§

high-dose ICS

either LTRA or

theophylline

§

high-dose ICS

either LTRA or

theophylline

§

oral corticosteroids

Consider subcutaneous allergen immunotherapy for

patients who have persistent, allergic asthma.

Quick-Relief

Medication

ƒ ƒ 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.

ƒ ƒ Caution: Increasing use of SABA or use >2 days/week for symptom relief (not to prevent EIB ) generally indicates

inadequate control and the need to step up treatment.

12 years of age

Intermittent

Asthma

Persistent Asthma: Daily Medication

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

Preferred

Treatment

SABA as needed low-dose ICS low-dose ICS

LABA
OR

medium-dose ICS

medium-dose

ICS
LABA

high-dose ICS

LABA
AND

consider

omalizumab for

patients who

have allergies

high-dose ICS

LABA

oral

corticosteroid

§§

AND

consider

omalizumab for

patients who

have allergies

Alternative

Treatment

, ‡

cromolyn, LTRA,

or theophylline

§

low-dose ICS

either LTRA,

theophylline,

§

or zileuton

medium-dose ICS

either LTRA,

theophylline,

§

or zileuton

Consider subcutaneous allergen immunotherapy

for patients who have persistent, allergic asthma.

Quick-Relief

Medication

ƒ ƒ 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.

ƒ ƒ Caution: Use of SABA >2 days/week for symptom relief (not to prevent EIB ) generally indicates inadequate control

and the need to step up treatment.

Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta 2

-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled

short-acting beta 2

-agonist.

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

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

§ Theophylline is a less desirable alternative because of the need to monitor serum concentration levels.

Based on evidence for 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.

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

Zileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.

§§ Before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton, may be considered, although this approach has not been studied

in clinical trials.

ASSESS

CONTROL:

STEP UP IF NEEDED (first, check medication adherence, inhaler technique, environmental control, and comorbidities)

STEP DOWN IF POSSIBLE (and asthma is well controlled for at least 3 months)

STEP 1

STEP 6

STEP 5

STEP 4

STEP 3

STEP 2

ESTIMATED COMPARATIVE DAILY DOSAGES:

INHALED CORTICOSTEROIDS FOR LONG-TERM ASTHMA CONTROL

0–4 years of age

5–11 years of age

12 years of age

Daily Dose

Low

Medium

High

Low

Medium

High

Low

Medium

High

MEDICATION Beclomethasone MDI

40 mcg/puff 80 mcg/puff

N/A
N/A
N/A

80–160 mcg

1–2 puffs

2x/day

1 puff 2x/day

160–320 mcg

3–4 puffs

2x/day

2 puffs 2x/day

320 mcg

3 puffs 2x/day

80–240 mcg

1–3 puffs

2x/day

1 puff am,

2 puffs pm

240–480 mcg

4–6 puffs

2x/day

2–3 puffs

2x/day

480 mcg

4 puffs

2x/day

Budesonide DPI

90 mcg/inhalation 180 mcg/ inhalation

N/A
N/A
N/A

180–360 mcg

1–2 inhs

2x/day

360–720 mcg 3–4 inhs

2x/day

2 inhs

2x/day

720 mcg

3 inhs

2x/day

180–540 mcg

1–3 inhs

2x/day

1 inh

am,

2 inhs

pm

540–1,080 mcg 2–3 inhs

2x/day

1,080 mcg

4 inhs

2x/day

Budesonide Nebules 0.25 mg 0.5 mg 1.0 mg

0.25–0.5 mg

1–2 nebs

/day

1 neb

/day

0.5–1.0 mg 2 nebs

/day

1 neb

/day

1.0 mg

3 nebs

/day

2 nebs

/day

0.5 mg

1 neb

2x/day

1 neb

/day

1.0 mg

1 neb

2x/day

1 neb

/day

2.0 mg

1 neb

2x/day

N/A
N/A
N/A

Ciclesonide MDI

80 mcg/puff 160 mcg/puff

N/A
N/A
N/A

80–160 mcg

1–2 puffs/day

1 puff/day

160–320 mcg

1 puff am,

2 puffs pm–

2 puffs 2x/day

1 puff 2x/day

320 mcg

3 puffs 2x/day

2 puffs 2x/day

160–320 mcg

1–2 puffs 2x/day

320–640 mcg 3–4 puffs 2x/day

2 puffs 2x/day

640 mcg

3 puffs 2x/day

Flunisolide MDI

80 mcg/puff

N/A
N/A
N/A

160 mcg

1 puff 2x/day

320–480 mcg

2–3 puffs 2x/day

480 mcg

4 puffs 2x/day

320 mcg

2 puffs 2x/day

320–640 mcg 3–4 puffs 2x/day

640 mcg

5 puffs 2x/day

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

Abbreviations:

DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.

USUAL DOSAGES FOR OTHER LONG-TERM CONTROL MEDICATIONS*

Medication 0–4 years of age 5–11 years of age ≥ 12 years of age

Combined Medication (inhaled corticosteroid + long-acting beta

2

-agonist)

Fluticasone/Salmeterol —

DPI

100 mcg/50 mcg, 250 mcg/50 mcg, or

500 mcg/50 mcg

MDI

45 mcg/21 mcg, 115 mcg/21 mcg, or

230 mcg/21 mcg

Budesonide/Formoterol

MDI

80 mcg/4.5 mcg or 160 mcg/4.5 mcg

Mometasone/Formoterol

MDI

100 mcg/5 mcg

N/A
N/A
N/A

1 inhalation 2x/day; dose

depends on level of

severity or control

2 puffs 2x/day; dose

depends on level of

severity or control

N/A†

1 inhalation 2x/day; dose

depends on level of severity

or control

2 puffs 2x/day; dose depends

on level of severity or control

2 inhalations 2x/day; dose

depends on severity of asthma

Leukotriene Modifiers

Leukotriene Receptor Antagonists (LTRAs)

Montelukast — 4 mg or 5 mg chewable tablet,

4 mg granule packets, 10 mg tablet

Zafirlukast — 10 mg or 20 mg tablet

Take at least 1 hour before or 2 hours after a meal.

Monitor liver function.

5-Lipoxygenase Inhibitor

Zileuton — 600 mg tablet

Monitor liver function.

4 mg every night at

bedtime (1–5 years of age)

N/A
N/A

5 mg every night at

bedtime (6–14 years of age)

10 mg 2x/day

(7–11 years of age)

N/A

10 mg every night at

bedtime

40 mg daily

(20 mg tablet 2x/day)

2,400 mg daily

(give 1 tablet 4x/day)

Immunomodulators

Omalizumab (Anti IgE

Subcutaneous injection, 150 mg/1.2 mL following

reconstitution with 1.4 mL sterile water for injection

Monitor patients after injections; be prepared to treat

anaphylaxis that may occur.

N/A
N/A

150–375 mg subcutaneous

every 2–4 weeks, depending

on body weight and

pretreatment serum IgE level

Cromolyn

Cromolyn — Nebulizer: 20 mg/ampule 1 ampule 4x/day, N/A

<2 years of age

1 ampule 4x/day 1 ampule 4x/day

Methylxanthines

Theophylline

Liquids, sustained-release tablets, and capsules

Monitor serum concentration levels.

Starting dose 10 mg/kg/

day; usual maximum:

ƒ ƒ <1 year of age: 0.2 (age in

weeks) + 5 = mg/kg/day

ƒ ƒ ≥1 year of age:

16 mg/kg/day

Starting dose 10 mg/

kg/day; usual maximum:

16 mg/kg/day

Starting dose 10 mg/kg/day

up to 300 mg maximum;

usual maximum:

800 mg/day

Inhaled Long-Acting Beta

2

-Agonists (LABAs) – used in conjunction with ICS

for long-term control; LABA is NOT to be used as monotherapy

Salmeterol — DPI

50 mcg/blister

Formoterol —DPI

12 mcg/single-use capsule

N/A
N/A

1 blister every 12 hours

1 capsule every 12 hours

1 blister every 12 hours

1 capsule every 12 hours

Oral Systemic Corticosteroids

Methylprednisolone — 2, 4, 8, 16, 32 mg tablets

Prednisolone — 5 mg tablets; 5 mg/5 cc, 15 mg/5 cc

Prednisone — 1, 2.5, 5, 10, 20, 50 mg tablets;

5 mg/cc, 5 mg/5 cc

ƒ ƒ 0.25–2 mg/kg daily

in single dose in a.m.

or every other day as

needed for control

ƒ ƒ Short course “burst”:

1–2 mg/kg/day, max 60

mg/d for 3–10 days

ƒ ƒ 0.25–2 mg/kg daily

in single dose in a.m.

or every other day as

needed for control

ƒ ƒ Short course “burst”:

1–2 mg/kg/day, max 60

mg/d for 3–10 days

ƒ ƒ 7.5–60 mg daily in single

dose in a.m. or every other

day as needed for control

ƒ ƒ Short course “burst”: to

achieve control, 40–60 mg/

day as single or 2 divided

doses for 3–10 days

  • 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: DPI, dry powder inhaler; IgE, immunoglobulin E; MDI, metered-dose inhaler; N/A, not available (not approved, no data available, or safety and efficacy not

established for this age group).

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.

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.

ƒ ƒ 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.

ƒ ƒ 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.

ƒ ƒ ICSs are generally safe for pregnant women.

Controlling asthma is important for pregnant women

to be sure the fetus receives enough oxygen.

ƒ ƒ ICSs are not addictive.

ƒ ƒ ICSs are not the same as anabolic steroids that some

athletes use illegally to increase sports performance.

RESPONDING TO PATIENT QUESTIONS ABOUT LONG-ACTING BETA

2

-AGONISTS

Keep the following key points in mind when

educating patients and families about long-acting

beta

2

-agonists (LABAs).

ƒ ƒ 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

beta

2

-agonists (SABA) for quick relief in most patients

to a greater extent than doubling the dose of ICS.

ƒ ƒ 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). 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.

ƒ ƒ 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.

ƒ ƒ 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.

ƒ ƒ Daily use should generally not exceed 100 mcg

salmeterol or 24 mcg formoterol.

ƒ ƒ It is not currently recommended that LABAs be used

to treat acute symptoms or exacerbations.

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.