Long-Term Management of Asthma

Essentials

• Teach the patient self-management in the follow-up and treatment Self-Management Education and Regular Practitioner Review for Adults with Asthma.
• The patient's own primary care physician checks the adequacy of the treatment regularly.
• The treatment aims at
  • minimal symptoms
  • normal functional ability
  • minimal need for an on-demand bronchodilator drug
  • no adverse effects of drugs
  • normal or the patient's best possible pulmonary function evaluated with spirometry and PEF monitoring
  • prevention of exacerbations.

Principles

• Inhaled glucocorticoids treat and suppress the asthmatic airway inflammation. They are an essential part of the treatment.
• All patients with asthma should also have a bronchodilator drug to be used as needed.
• Teaching and follow-up of the inhalation technique of drugs is important.
• The treatment should be tailored for each patient according to the severity of the disease and modified flexibly step-by-step. Self-management of drug dosing is encouraged (written instructions!).
  • Provide advice on local information sources.
• As necessary, inhaled glucocorticoid is combined with a long-acting beta2 agonist, long-acting anticholinergic or leukotriene receptor antagonist.
• Short courses of oral glucocorticoids are occasionally needed.
  • In association with a viral infection, a symptom-relieving drug (usually a short-acting beta2 agonist) is used regularly. If this is not sufficient, an oral glucocorticoid course is started. A combination of budesonide and formoterol may also be used as symptomatic therapy. If the patient uses anti-inflammatory medication only periodically (e.g. during the pollen season), the anti-inflammatory medication should be, however, used regularly also in the event of a viral infection.
• High allergen concentrations may increase symptoms in a patient with allergic asthma. For example, it is not recommended for a person who has asthma and is allergic to cats to have a cat as a home pet.
• High concentrations of airway irritants (dusts, fumes, chemicals) usually increase the occurrence of asthmatic symptoms.
• It should be noted that people who are hypersensitive to NSAIDs cannot use aspirin or other NSAIDs (including metamizole). Approximately 10-20% of patients with asthma are hypersensitive to these drugs.
• Non-selective beta-blockers often exacerbate the symptoms of asthma.
• Smoking cessation is actively supported.
• Allergen immunotherapy Allergen Immunotherapy may help some patients Allergen Immunotherapy for Asthma.

Implementation Intermittent Versus Daily Inhaled Corticosteroids for Persistent Asthma, Intermittent Inhaled Corticosteroid Versus Placebo for Persistent Asthma

1. The patient has asthma symptoms only occasionally (less frequently than once a week and nightly symptoms not more frequently than twice a month) and the pulmonary function tests are normal:
   • allergy proofing of the environment and cessation of smoking Smoking Cessation
     • Reducing mite allergen levels in the environment is difficult, and there is no evidence of benefit House Dust Control Measures for Asthma.
   • inhaled short-acting bronchodilator drug as needed Regular Vs. as-Needed Inhaled Short Acting Beta2-Agonist Use in Asthma (salbutamol or terbutalin or a combination preparation of budesonide and formoterol or a combination preparation of fenoterol and ipratropium bromide).
2. If the symptoms are more frequent and inhaled bronchodilator drugs are needed more often than once a week or if sleep is disturbed by asthma, adding regular anti-inflammatory medication is indicated.
   • Inhaled glucocorticoid Inhaled Corticosteroids in the Long-Term Management of Asthma, depending on the product 100-400 µg twice (beclomethasone Beclomethasone for Chronic Asthma, budesonide Budesonide for Chronic Asthma, fluticasone propionate Inhaled Fluticasone Propionate for Asthma) or once (fluticasone furoate [only in combination preparations], ciclesonide Ciclesonide for Chronic Asthma, mometasone Mometasone for Chronic Asthma) daily Initial Starting Dose of Inhaled Corticosteroids for Asthma, Inhaled Vs Oral Steroids for Adults with Bronchial Asthma
     • Inhalation powders are usually the primary choice, easy to use and well tolerated. However, patients with weakened respiratory muscles or severely lowered vital capacity should preferably take their drugs as dose aerosols using a spacer.
     • Pulmonary concentration of drugs in aerosol form are usually better if they are taken with an inhalation spacer.
     • For clinically comparable doses of inhaled glucocorticoids, see table T1.
   • A leukotriene antagonist Anti-Leukotrienes for Asthma (e.g. montelukast 10 mg for the night) may be used as an alternative. Leukotriene antagonists are particularly apt for patients who are not able to use inhaled drugs. They are well tolerated, but the effect in usual licensed doses is inferior to inhaled glucocorticoids Anti-Leukotrienes Versus Inhaled Corticosteroids in the Treatment of Asthma.
3. If the symptoms continue daily, if the need for an on-demand bronchodilator drug is frequent, and obstruction is present according to PEF monitoring:
   • Check the inhalation techniques, recognize any factors that might worsen the asthma and verify the patient's compliance.
   • To be used in addition to the inhaled glucocorticoid, add
     • a long-acting bronchodilator drug Long-Acting Beta2-Agonists in Addition to Inhaled Corticosteroids in Chronic Asthma Combination of Inhaled Long-Acting Beta-2 Agonists and Inhaled Steroids Versus Higher Dose of Inhaled Steroids in Persistent Asthma, Long-Acting Beta2-Agonists Versus Anti-Leukotrienes as Add-on Therapy to Inhaled Corticosteroids for Chronic Asthma, Safety of Regular Formoterol or Salmeterol in Adults with Asthma (salmeterol 50 µg twice daily, formoterol 6-24 µg twice daily); combined preparations containing both an inhaled glucocorticoid and a long-acting bronchodilator drug may be used instead. Single Inhaler Combination of Formoterol and Budesonide Versus Inhaled Steroid Maintenance for Chronic Asthma
     • a leukotriene antagonist Long-Acting Beta2-Agonists Versus Anti-Leukotrienes as Add-on Therapy to Inhaled Corticosteroids for Chronic Asthma
     • tiotropium bromide.
4. If the symptoms are not controlled adequately with a combination of a daily dose of inhaled glucocorticoid corresponding to 800 µg of budesonide (table T1) and a long-acting bronchodilator drug, added with a short-acting inhaled bronchodilator drug when needed, add one or more of the following:
   • inhaled steroid at the maximum daily dose (depends on the preparation)
   • leukotriene antagonist Addition of Anti-Leukotriene Agents to Inhaled Corticosteroids for Chronic Asthma (montelukast or zafirlukast)
   • tiotropium bromide once daily Tiotropium Added to Long-Acting Beta-Agonist and Inhaled Corticosteroid (Laba+ics) for Adults with Asthma
   • change inhaled maintenance medication for a triple preparation (inhaled glucocorticoid, long-acting beta-2 agonist and anticholinergic)
   • In some cases, the following add-on drugs may be tried:
     • bronchodilator drug administered with a nebulizer
     • omalizumabOmalizumab for Asthma (anti-IgE; for allergic asthma)
     • mepolizumab, reslizumab, benralizumab (anti-IL5 and anti-IL5R; for eosinophilic asthma) or dupilumab (anti-IL4R; for eosinophilic asthma), tezepelumab (anti-TSLP)
     • regular use of a low-dose glucocorticoid in tablet form
     • azithromycin 3 times a week.
   • Initiation of biological drug treatments has been concentrated to specialized care. Thermoplasty may also be considered if the patient's asthma cannot be controlled with drug therapy Bronchial Thermoplasty for Moderate or Severe Persistent Asthma in Adults.
5. During exacerbation, an oral glucocorticoid course is used (more details below).