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:

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

 

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

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