Table 1. Stepwise Approach for Managing Asthma in Adults and Children Over 5 Years Old: Treatment
(Preferred treatments are in bold print)¹

Severe Persistent

* Anti-inflammatory: inhaled corticosteroid (high dose) AND

* Long-acting bronchodilator: either long-acting inhaled beta-2 agonist, sustained release theophylline, or long-acting beta-2 agonist tablets AND

* Corticosteroid tablets or syrup long term (2mg/kg/day, generally do not exceed 60mg per day).

* Intensity of treatment will depend on severity of exacerbation.

* Use of short-acting inhaled beta-2 agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Moderate Persistent

* Either anti-inflammatory: inhaled corticosteroid (medium dose) OR inhaled corticosteroid (low-medium dose) and add a long-acting bronchodilator, especially for nighttime symptoms: either long acting inhaled beta-2 agonist, sustained release theophylline, or long-acting beta-2 agonist tablets.

* If needed, anti-inflammatory: inhaled corticosteroids (medium-high dose) AND long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta-2 agonist, sustained-release theophylline, or long-acting beta-2 agonist tablets.

* Intensity of treatment will depend on severity of exacerbation.

* Use of short-acting inhaled beta-2 agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Mild Persistent

* Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil).

* Sustained-release theophylline to serum concentration of 5-15 mcg/mL is an alternative. Zafirulkast or zileuton may also be considered for patients greater than or equal to 12 years of age, although their position in therapy is not fully established.

* Intensity of treatment will depend on severity of exacerbation.

* Use of short-acting inhaled beta-2 agonists on a daily basis or increasing use, indicates the need for additional long-term control therapy.

Mild Intermittent

* Intensity of treatment will depend on severity of exacerbation.

* Use of short-acting inhaled beta-2 agonists more than two times a week may indicate the need to initiate long-term-control therapy.

Table 2. Usual Dosages for Long-Term-Control Medications¹

Methylprednisolone

Prednisolone

Prednisone

5 mg tablets, 5mg/5cc, 15mg/5cc

1, 2.5, 5, 10, 20, 25 mg tablets; 5mg/cc, 5mg/5cc

Short-course "burst": 40-60 mg per day as single or 2 divided doses for 3-10 days

Short-course "burst": 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days

* Short courses or "bursts" are effective for establishing control when initiating therapy or during a period of gradual deterioration.

Cromolyn

Nedocromil

Nebulizer solution

20 mg/ampule

MDI 1.75 mg/puff

1 ampule tid-qid

2-4 puffs bid-qid

1 ampule tid-qid

1-2 puffs bid-qid

Salmeterol

Sustained-Release albuterol

DPI 50 mcg/blister

4 mg tablet

1 blister q 12 hours

4 mg q 12 hours

1 blister q 12 hours

0.3-0.6 mg/kg/day, not to exceed 8 mg/day

* Do not use salmeterol as a rescue inhaler for symptom relief or for exacerbations.

Theophylline

Sustained-release tablets and capsules

>= 1 year of age:

16 mg/kg/day

< 1 year: 0.2(age in weeks) + 5 = mg/kg/day

* Due to wide interpatient variability in theophylline metabolic clearance, routine serum theophylline level monitoring is important. Many factors can affect levels.

Zafirlukast

Zileuton

300 mg tablet

600 mg tablet

* For zileuton, monitor hepatic enzymes(ALT).

Table 3. Estimated Comparative Daily Dosages for Inhaled Corticosteroids¹

42 mcg/puff

84 mcg/puff

(4-12 puffs of 42 mcg)

(2-6 puffs of 84 mcg)

(12-20 puffs of 42 mcg)

(6-10 puffs of 84 mcg)

(> 20 puffs of 42 mcg)

(> 10 puffs of 84 mcg)

200 mcg/dose

(1-2 inhalations)

(2-3 inhalations)

(> 3 inhalations)

250 mcg/puff

(2-4 puffs)

(4-8 puffs)

(> 8 puffs)

MDI: 44, 110, 220 mcg/puff

DPI: 50, 100, 250 mcg/puff

(2-6 puffs of 44 mcg) or

(2 puffs of 110 mcg)

(2-6 inhalations of 50 mcg)

(2-6 puffs of 110 mcg)

(3-6 inhalations of 100 mcg)

(> 6 puffs of 110 mcg) or

(> 3 puffs of 220 mcg)

(> 6 inhalations of 100 mcg) (> 2 inhalations of 250 mcg)

100 mcg/puff

(4-10 puffs)

(10-20 puffs)

(>20 puffs)

42 mcg/puff

84 mcg/puff

(2-8 puffs of 42 mcg)

(1-4 puffs of 84 mcg)

(8-16 puffs of 42 mcg)

(4-8 puffs of 84 mcg)

(> 16 puffs of 42 mcg)

(> 8 puffs of 84 mcg)

200 mcg/dose

(1-2 inhalations of 200 mcg)

(> 2 inhalations of 200 mcg)

250 mcg/puff

(2-3 puffs)

(4-5 puffs)

(>5 puffs)

MDI: 44, 110, 220 mcg/puff

DPI: 50, 100, 250 mcg/dose

(2-4 puffs of 44 mcg)

(2-4 inhalations of 50 mcg)

(4-10 puffs of 44 mcg) or

(2-4 puffs of 110 mcg)

(2-4 inhalations of 100 mcg)

(> 4 puffs of 110 mcg) or

(> 2 puffs of 220 mcg)

(> 4 inhalations of 100 mcg) (> 2 inhalations of 250 mcg)

100 mcg/puff

(4-8 puffs)

(8-12 puffs)

(> 12 puffs)

Table 4. Usual Dosages for Quick-Relief Medications¹

Albuterol

Albuterol HFA

Bitolterol

Pirbuterol

Terbutaline

Albuterol Rotahaler

Albuterol

Bitolterol

90 mcg/puff, 200 puffs

90 mcg/puff, 200 puffs

370 mcg/puff, 300 puffs

200 mcg/puff, 400 puffs

200 mcg/puff, 300 puffs

DPI's

200 mcg/capsule

Nebulizer Solution

5 mg/ml (0.5%)

2 mg/ml (0.2%)

2 puffs tid-qid

1-2 capsule q 4-6 hours as needed and prior to exercise

1.25-5 mg (0.25-1cc) in 2-3 cc of saline q 4-8 hours

0.5-3.5 mg (0.25-1cc) in 2-3 cc of saline q 4-8 hours

2 puffs tid-qid

1 capsule q 4-6 hours as needed and prior to exercise

0.05mg/kg (min 1.25 mg, max 2.5 mg) in 2-3 cc of saline q 4-6 hours

Not established

* Not generally recommended for long-term treatment. Regular use on a daily basis indicates the need for additional long-term control therapy.

* Differences in potency exist so that all products are essentially equipotent on a per puff basis.

* May double usual dose for mild exacerbations.

* Nonselective agents (epinephrine, isoproterenol, metaproterenol) are not recommended due to their potential for excessive cardiac stimulation, especially at high doses.

* May mix albuterol nebulizer solution with cromolyn or ipratropium nebulizer solutions. May double dose for mild exacerbations.

* May not mix bitolterol with other nebulizer solutions.

Ipratropium

18 mcg/puff, 200 puffs

Nebulizer solution

0.25 mg/ml (0.025%)

0.25-0.5 mg q 5 hours

0.25 mg q 6 hours

Methylprednisolone

Prednisolone

Prednisone

5 mg tabs, 5 mg/5cc, 15mg/5cc

1, 2.5, 5, 10, 20, 25mg tablets; 5 mg/cc, 5 mg/5cc