Asthma Stepwise Formulary FOR DAILY CONTROL MEDICATION QuickGuide to abbreviations: step 6 2014 • ICS: inhaled corticosteroid step 5 • LABA: long-acting beta2-agonist Asthma Control HIGH-DOSE ICS • LTRA: leukotriene receptor antagonist (per step 5) • SABA: short-acting beta2-agonist step 4 LTRA (per step 4) for the care of pediatric and adult patients + LTRA (per step 4) + HIGH-DOSE ICS with established asthma step 3 (mark choice): + oral systemic steroids MEDIUM-DOSE ICS fluticasone (Flovent) MDI: (lowest dose for the shortest (per step 3; mark a choice there) 110 mcg: 2 puffs twice daily duration: 5-10 mg is A tool for ongoing assessment considered low-dose) MEDIUM-DOSE ICS + LTRA: montelukast budesonide (Pulmicort) respules: and treatment adjustment step 2 (mark choice): (Singulair) by mouth: 1.0 mg: 1 respule twice daily 4 mg: 1 tablet once daily, or fluticasone (Flovent) MDI: 1 packet oral granules once daily 110 mcg: 1 puff twice daily HIGH-DOSE ICS budesonide (Pulmicort) respules: (per step 5) LOW-DOSE ICS (mark choice): LABA (per step 3) 0.50 mg: 1 respule twice daily + LABA (per step 4) fluticasone (Flovent) MDI: + HIGH-DOSE ICS LABA (per step 3) Inside the QuickGuide... 44 mcg: 2 puffs twice daily (mark choice): + oral systemic steroids budesonide (Pulmicort) respules: + MEDIUM-DOSE ICS fluticasone (Flovent) MDI: (lowest dose for the shortest 0.25 mg: 1 respule twice daily (mark choice): • Asthma control tables step 1 110 mcg: 2 puffs twice daily duration: 5-10 mg is considered low-dose) fluticasone (Flovent) MDI: beclomethasone (Qvar) MDI: • Stepwise medication therapy LOW-DOSE ICS 110 mcg: 1 puff twice daily 80 mcg: 2-3 puffs twice daily (per step 2; mark a choice there) LOW-DOSE ICS (mark choice): beclomethasone (Qvar) MDI: budesonide (Pulmicort) DPI: • Daily dose chart for inhaled + LABA: salmeterol 80 mcg: 1-2 puffs twice daily fluticasone (Flovent) MDI: 180 mcg: 3 inhalations twice daily (Serevent) DPI: budesonide (Pulmicort) DPI: corticosteroids (ICS) 44 mcg: 1-2 puffs twice daily budesonide (Pulmicort) respules: 50 mcg: 1 inhalation twice daily 180 mcg: 1-2 inhalations twice daily 1 mg: 1 respule twice daily beclomethasone (Qvar) MDI: or budesonide (Pulmicort) respules: 40 mcg: 1-2 puffs twice daily mometasone (Asmanex) DPI: + LTRA: montelukast 0.50 mg: 1 respule twice daily 220 mcg: 2 inhalations once daily budesonide (Pulmicort) DPI: (Singulair) by mouth: HIGH-DOSE ICS mometasone (Asmanex) DPI: 90 mcg: 1-2 inhalations twice daily (per step 5) 5 mg: 1 tablet once daily 220 mcg: 1 inhalation once daily budesonide (Pulmicort) respules: + LABA (per step 4) 0.25 mg: 1 respule twice daily + oral systemic steroids mometasone (Asmanex) DPI: MEDIUM-DOSE ICS LABA (per step 3) 110 mcg: 1 inhalation once daily (per step 4; mark a choice there) + HIGH-DOSE ICS (lowest dose for the shortest LABA (or LTRA) (per step 3) (mark choice): duration: 5-10 mg is considered low-dose) + MEDIUM-DOSE ICS fluticasone (Flovent) MDI: (mark choice): LOW-DOSE ICS (mark choice): 220 mcg: 1-2 puffs twice daily fluticasone (Flovent) MDI: LOW-DOSE ICS fluticasone (Flovent) MDI: beclomethasone (Qvar) MDI: 110 mcg: 1-2 puffs twice daily 80 mcg: 3-4 puffs twice daily 44 mcg: 1-3 puffs twice daily (per step 2; mark a choice there) beclomethasone (Qvar) MDI: budesonide (Pulmicort) DPI: beclomethasone (Qvar) MDI: + LABA (or LTRA): salmeterol 40 mcg: 1-3 puffs twice daily 80 mcg: 2-3 puffs twice daily 180 mcg: 3-4 inhalations twice daily NO DAILY CONTROL MEDICATION. CONTROL NO DAILY (Serevent) DPI: budesonide (Pulmicort) DPI: mometasone (Asmanex) DPI: SABA as needed steps, in all ages. all budesonide (Pulmicort) DPI: 50 mcg: 1 inhalation twice daily 180 mcg: 1 inhalation twice daily 180 mcg: 2-3 inhalations twice daily 220 mcg: 2-3 inhalations once daily mometasone (Asmanex) DPI: mometasone (Asmanex) DPI: MEDIUM-DOSE ICS 220 mcg: 1 inhalation once daily 220 mcg: 1-2 inhalations once daily (per step 4; mark a choice there) For a comprehensive summary of evidence-based guidelines • Check Inhaler technique Check ICE before stepping up therapy; also, if alternative for asthma diagnosis and treatment, see Intermountain’s • Check Compliance medication therapy is used and response is inadequate, • Check Environmental history and trigger management Asthma Care Process Model (CPM) online at switch to preferred treatment before stepping up. Follow up: Depending on severity, assess asthma control in 2 to 6 weeks after intermountainhealthcare.org/clinicalprograms medication is initiated or stepped up. If no clear benefit is observed in 4 to 6 weeks, © 2008-2014 Intermountain Healthcare. All rights reserved. Patient and Provider Publications consider adjusting therapy or alternative diagnoses. 801-442-2963 CPM017b - 02/14 The level of asthma control is based on the most severe impairment or risk category. ALL components — including spirometry — are important for assessing control. Stepwise medication therapy for asthma Asthma Control tables. See the Asthma Care Process Model (CPM) for a full summary of evidence-based guidelines: intermountainhealthcare.org/clinicalprograms • Initiate stepwise therapy based on severity classification at diagnosis. • Manage asthma triggers and educate patient/family at each step. Patients age 0 to 4 years Asthma CONTROL classifications • Adjust therapy based on control tables at left: step up when necessary, step down when possible. CONTROL components Well controlled Not well controlled Very poorly controlled < Impairment Symptoms 2 days/week >2 days/week Throughout the day Consult with Nighttime awakenings < 1 time/month >1 time/month >1 time/week asthma specialist for step 3 and above Step 6 Interference with normal activity None Some limitation Extremely limited Consider High-dose ICS SABA use for Sx (NOT EIB-prevention) < 2 days/week >2 days/week Several times/day consultation with Step 5 asthma specialist + Exacerbations requiring 0 to 1 time/year 2 to 3 times/year >3 times/year at step 2 Step 4 High-dose Risk oral corticosteroids ICS either LTRA or Medium- LABA Medication side effects can vary in intensity from none to very troublesome and worrisome. Step 3 + Treatment-related adverse effects dose ICS The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. + Step 2 Medium- + either LTRA or dose ICS LABA Recommended actions • Maintain current medication. • Step up current medication (one step)and reassess • Consider a short course of oral systemic corticosteroids oral systemic Step 1 Low-dose ICS either LTRA or steroids based on level of control • Reinforce education and trigger management. control in 2 to 6 weeks. • Step up current medication (one or two steps)* and reassess LABA Alternatives: • Follow up every 1 to 6 months. • If no clear benefit in 4 to 6 weeks, control in 2 weeks. No daily cromolyn, LTRA consider alternative diagnoses or adjusting therapy. • If no clear benefit in 4 to 6 weeks, consider alternative controller • Consider stepping down medication therapy medication • For side effects, consider alternative treatment options. diagnoses or adjusting therapy. For daily doses at conclusion of winter viral season if well SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn • For side effects, consider alternative treatment options. controlled for at least 3 months. • Reinforce education and trigger management. for quick-relief for quick-relief for quick-relief for quick-relief for quick-relief for quick-relief of ICS for each • Reinforce education and trigger management age group, see Patients age 5 to 11 years Asthma CONTROL classifications the back of this Consult with asthma specialist QuickGuide. CONTROL components Well controlled Not well controlled Very poorly controlled Consider for step 4 and above consultation with Symptoms <2 days/week but not more than once each day >2 days/week or multiple times on < 2 days/week Throughout the day asthma specialist Step 6 Impairment at step 3 Nighttime awakenings <1 time/month >2 times/month >2 times/week Step 5 High-dose ICS Interference with normal activity None Some limitation Extremely limited + High-dose SABA use for Sx (NOT EIB-prevention) <2 days/week >2 days/week Several times/day Step 4 LABA ICS • FEV or peak flow >80% predicted/personal best • FEV or peak flow 60% to 80% predicted/personal best • FEV or peak flow <60% predicted/personal best Step 3 Medium- + Lung function/spirometry 1 1 1 dose ICS + • FEV /FVC >80% • FEV /FVC 75% to 80% • FEV /FVC <75% oral systemic 1 1 1 Step 2 Either... + LABA steroids Exacerbations requiring 0 to 1 time/year >2 times/year low-dose ICS Risk Low-dose ICS + either LTRA, LABA Alternative: Alternatives: Abbreviations: oral corticosteroids Consider severity and interval since last exacerbation. Step 1 High-dose ICS + LABA, or High-dose ICS • ICS: Alternatives: theophylline Alternative: + either LTRA or either LTRA Reduction in lung growth Evaluation requires long-term follow-up. No daily cromolyn, LTRA Medium-dose or theophylline controller theophylline inhaled Possible medication side effects can vary in intensity from none to very troublesome and worrisome. nedocromil, or ICS + either + oral systemic Treatment-related adverse effects medication OR steroids corticosteroid The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. theophylline LTRA or theoph- ylline medium-dose • LABA: Recommended actions • Maintain current medication. • Step up current medication (one step) and reassess • Consider a short course of oral systemic corticosteroids. ICS long-acting based on level of control • Reinforce education and trigger management. control in 2 to 6 weeks. • Step up current medication (one or two steps) and reassess beta -agonist; • Follow up every 1 to 6 months. • For side effects, consider alternative treatment options. control in 2 weeks. SABA prn SABA prn SABA prn SABA prn SABA prn SABA prn 2 • Consider stepping down medication therapy for quick-relief for quick-relief for quick-relief for quick-relief for quick-relief for quick-relief • LTRA: • Reinforce education and trigger management.