NHLBI steps 1-6:

2009 NHLBI Stepwise Approach for Managing Asthma in Adults and Youth ≥ 12 years old
NHLBI Step	Treatment of choice	Alternatives
Step 1 Intermittent asthma	short-acting beta-2 agonist (SABA) as needed	for exacerbations due to viral respiratory infections SABA every 4-6 hours for 24 hours (longer with physician consult) consider 3-10 days of oral systemic corticosteroids if moderate-to-severe exacerbation or history of severe exacerbation
Step 2 Persistent asthma	low-dose inhaled corticosteroid (ICS) consider subcutaneous allergen immunotherapy if patient has allergic asthma	cromolyn, leukotriene receptor antagonist (LTRA), nedocromil, or theophylline
Step 3 Persistent asthma	low-dose ICS and long-acting beta-2 agonist (LABA), or medium-dose ICS consider subcutaneous allergen immunotherapy if patient has allergic asthma	low-dose ICS and either LTRA, theophylline or zileuton (zileuton requires monitoring liver function, theophylline requires monitoring serum concentrate levels)
Step 4 Persistent asthma	medium-dose ICS and LABA consider subcutaneous allergen immunotherapy if patient has allergic asthma	medium-dose ICS and either LTRA, theophylline or zileuton
Step 5 Persistent asthma	high-dose ICS and LABA consider omalizumab for patients who have allergies	none
Step 6 Persistent asthma	high-dose ICS and LABA and oral corticosteroid consider omalizumab for patients who have allergies	before oral corticosteroids are introduced, a trial of high dose ICS and LABA and either LTRA, theophylline, or zileuton may be considered

Recommended steps for initial therapy based on severity of asthma:

• intermittent asthma - step 1
• mild persistent asthma - step 2
• moderate persistent asthma - step 3 and consider short course of oral corticosteroids
• severe persistent asthma - step 4 or 5 and consider short course of oral corticosteroids
• evaluate level of asthma control in 2-6 weeks and adjust therapy accordingly

Severity Classification for Patients > 12 Years Old Not Currently Taking Long-term Control Medication
Components of Severity		Classification of Asthma Severity
		Intermittent	Persistent
			Mild	Moderate	Severe
Impairment	symptoms	≤ 2 days weekly	> 2 days weekly but not daily	daily	throughout the day
	nighttime awakenings	≤ 2 days monthly	3-4 times monthly	> once weekly but not nightly	often 7 times weekly
	short-acting beta-2 agonists use for symptom control (not prevention of exercise-induced bronchospasm)	≤ 2 days weekly	> 2 days weekly but not daily, and no more than once daily	daily	several times daily
	interference with normal activity	none	minor limitation	some limitation	extremely limited
	lung function	normal FEV1 between exacerbations FEV1 > 80% predicted FEV1/FVC normal	FEV1 > 80% predicted FEV1/FVC normal	FEV1 60-80% predicted FEV1/FVC reduced 5%	FEV1 > 60% predicted FEV1/FVC reduced > 5%
Risk	exacerbations requiring oral systemic corticosteroids	0-1 times yearly	≥ 2 times yearly
		consider severity and interval since last exacerbation; frequency and severity may fluctuate over time for patients in any severity category

• FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity

Principles of stepwise management of asthma in adults and youth ≥ 12 years old:

• initiate therapy based on asthma severity and adjust therapy based on level of control (Evidence A)⁽¹⁾
• assess asthma control in terms of current impairment and risk of adverse events (Evidence C)
• address both domains to select appropriate therapy - see Asthma severity classification
• classify level of control based on most severe indicator of impairment or risk (Evidence D)
• if alternative treatment is used and response inadequate
• discontinue
• use treatment of choice before stepping up
• increase dose, frequency and number of medications as necessary (Evidence B)
• decrease when possible (Evidence D)
• evaluate 2-6 weeks after starting and adjusting therapy (Evidence D)⁽¹⁾
• at each step
• advise patients to avoid or control allergens (Evidence A ), irritants or comorbid conditions that make asthma worse (Evidence B)
• written action plan recommended, especially if moderate or severe asthma, history of severe exacerbation, or poorly controlled asthma (Evidence B)
• if patient's asthma not well controlled⁽¹⁾
• step up to next higher step may be necessary (Evidence A)
• quick relief medication
• short-acting beta-2 agonist (SABA) as needed for symptoms based on severity
• ≤ 3 treatments at 20-minute intervals
• short course of oral systemic corticosteroids may be needed
• SABA > 2 days/week for symptom relief (not prevention of exercise-induced bronchospasm) usually indicates inadequate control, need to step up treatment
• if very poor control, consider
• increase by two steps
• course of oral corticosteroids
• before stepping up, check
• adherence and technique in using medications (Evidence B)
• environmental control
• comorbid conditions (Evidence C) such as
• rhinitis or sinusitis
• gastroesophageal reflux
• obesity
• increased exposure to allergens or irritants
• psychosocial problems
• family barriers to management behaviors
• alternative diagnoses such as vocal cord dysfunction
• consider step up if office spirometry suggests worse control than assessment of impairment based on other measures
• if patient experiences troublesome or debilitating side effects (Evidence D)⁽¹⁾
• consider alternative and/or adjunctive therapies within the step of care
• confirm efforts to control environmental exposures
• consultation with asthma specialist recommended (Evidence D)⁽¹⁾
• if difficulties achieving or maintaining control
• if patient requires step 4 care or higher
• consider referral if patient requires step 3 care
• provide patient education to achieve optimal pharmacologic therapy (Evidence A)⁽¹⁾
• when good control maintained for ≥ 3 months consider step-down to identify minimum therapy required (Evidence D)⁽¹⁾

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