Table 1: Maintenance Treatment according to Severity of Symptoms
Back to Asthma Chapter
| Severity | Classification Criteria | Treatment |
|---|
*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
