Asthma, Known or New Diagnosis Clinical Pathway — Asthma Treatment: Step up, step down — Primary Care

Known or Suspected Asthma Clinical Pathway — Primary Care

Asthma Treatment: Step Up, Step Down

Stepwise Recommended Medication Escalation Treatment for Managing Asthma Long-Term

Adapted from 2020 Focused Updates to the Asthma Management Guidelines: Clinician's Guide  . See full guide for alternative management.

Age
(yrs)		 Step 1 Step 2 Step 3 Step 4 Consider Asthma Biologics
Step 5 Step 6
Severity Intermittent Mild Persistent Moderate Persistent Severe Persistent
0-4
Preferred
Medications

SABA as needed for symptoms

And at the start of RTI add short course of daily ICS 		Low-dose ICS and PRN SABA Medium dose ICS and PRN SABA Daily medium-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA + OCS and PRN SABA
5-12 Preferred
Medications		 SABA as needed for symptoms Daily low-dose ICS Daily and PRN combination low-dose ICS-formoterol Daily and PRN medium-dose ICS-formoterol Daily high-dose ICS-LABA and PRN SABA Daily high-dose ICS-LABA + OCS and PRN SABA
≥ 12 Preferred
Medications		 SABA as needed for symptoms Daily low-dose ICS and PRN SABA or PRN concomitant ICS and SABA Daily and PRN combination low-dose ICS-formoterol Daily and PRN combination medium-dose ICS-formoterol Daily medium or high-dose ICS-LABA + LAMA and PRN SABA Daily high-dose ICS-LABA + OCS + PRNs SABA
Quick Relief

Use SABA as needed for symptoms. The intensity of treatment depends on the severity of symptoms:
up to 3 treatments at 20 min intervals as needed.

In steps 3 and 4, the preferred option includes the use of ICS-formoterol 1 to 2 puffs as needed up to
a maximum total daily maintenance and rescue dose of 8 puffs (< 12 yrs) and 12 puffs (≥ 12 yrs).
  • Abbreviations —
    • ICS Inhaled corticosteroids,
    • LABA Long-acting beta agonist,
    • OCS Oral corticosteroids,
    • SABA Short-acting beta agonist,
    • SMART Single maintenance and reliever therapy,
    • LAMA Long-acting muscarinic antagonist

Guidance for Step Up/Down Based on Control

  1. Check adherence, inhaler technique, environmental factors, and comorbid conditions
  2. Assess asthma control, step up, down accordingly
  3. Consultation with asthma specialist
    1. Recommended at Step 4 or higher
    2. Consider at Step 3
  4. Follow-up based on level of control spirometry on a regular basis (FEV, FEV1/FVC)

Assessment of Asthma Control

  • Asthma control assessment should occur at least once a year for all levels of asthma severity
  • Use Asthma Control Tool
Symptoms
  • Flares (an increase in symptoms > 1 day)
  • Nighttime symptoms
  • Missed school or daycare
  • Exacerbated by activity (play, exercise, running, sports)
  • Required albuterol (quick-relief medicine)
Risks for Adverse Outcomes
  • Visits to ED or urgent care
  • Hospital admission
  • Oral corticosteroids (prednisone, prednisolone, or dexamethasone)

Asthma Assessment Categories

Control Level Symptoms Management and Assessment Frequency
Well-controlled No symptoms, no risk
  • Decrease controller medication 25-50% every 2-3 mos if controlled
  • Follow-up in 3-6 mos
Not Well-controlled Symptoms or risks
  • Step up 1 step
  • Follow-up in 2-6 wks
Poorly Controlled Symptoms and risks
  • Oral corticosteroids or step up 2 steps
  • Follow-up every 2 wks until controlled
  • If no improvement, consider alternative diagnosis