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Asthma: Maintenance Treatment according to Severity of Symptoms

for Health Care Providers

Table 1: Maintenance Treatment according to Severity of Symptoms

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SeverityClassification CriteriaTreatment

*There are important interactions between some inhaled corticosteroids and certain ARVs. See Table 4: Potential ARV Interactions.

Intermittent
  • Symptoms ≤2 days/week
  • Nighttime awakenings ≤2/month
  • SABA use ≤2 days/week
  • No interference with normal activity
  • FEV1>80% predicted or PEFR >80% personal best; FEV1/FVC normal
  • 0-1 exacerbations requiring oral steroids per year
Step 1:
  • SABA, (eg, albuterol, levalbuterol, pirbuterol)
Mild Persistent
  • Symptoms >2 days/week
  • Nighttime awakenings 3-4/month
  • SABA >2 days/week but not daily
  • Minor limitation with normal activity
  • FEV1 or PEFR ≥80%; FEV1/FVC normal
  • ≥2 exacerbations requiring oral steroids per year
Step 2:
  • Low-dose inhaled corticosteroid (ICS)* (use lowest effective dosage; see medication chart for details)
  • SABA, as needed
Alternatives: cromolyn, leukotriene receptor antagonist (montelukast, zafirlukast), nedocromil, theophylline
Moderate Persistent
  • Symptoms daily
  • Nighttime awakenings >1/week but not daily
  • SABA daily
  • Some limitation with normal activity
  • FEV1 or PEFR >60% and <80%, or FEV1/FVC reduced 5%
  • ≥2 exacerbations requiring oral steroids per year
Step 3:
  • Low-dose ICS* and long-acting beta-agonist (LABA) (eg, salmeterol or formoterol)
OR
  • Medium-dose ICS*
  • Consider short course of oral steroids (eg, prednisone 40 mg QD for 5 days) when initiating treatment
  • SABA, as needed
Alternatives: low-dose ICS* with leukotriene receptor antagonist, theophylline, or zileuton
Severe Persistent
  • Symptoms throughout the day
  • Nighttime awakenings daily
  • SABA several times per day
  • Extreme limitation with normal activity
  • FEV1 or PEFR <60%, or FEV1/FVC reduced >5%
  • ≥2 exacerbations requiring oral steroids per year
Step 4:
  • High-dose ICS* and LABA
  • Combination ICS and LABA options include budesonide/formoterol and fluticasone/salmeterol*
Step 5 (add to above):
  • Consider omalizumab for patients with allergies, as evaluated by an immunologist

From Asthma
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009