In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly Step 1 Step 2 Step 3 Step 4 or 5 Relative annual risk of exacerbations may be related to FEV 0-2/year > 2 /year Frequency and severity may vary over time for patients in any category <2 days/week >2 days/week not daily Daily Continuous <2x/month 3-4x/month >1x/week not nightly Often nightly none Minor limitation Some limitation Extremely limited <2 days/week >2 days/week not daily Daily Several times daily Consider short course of oral steroids • Normal FEV 1 between exacerbations • FEV 1 > 80% • FEV 1 /FVC normal • FEV 1 >80% • FEV 1 /FVC normal • FEV 1 >60% but< 80% • FEV 1 /FVC reduced 5% • FEV 1 <60% • FEV 1 /FVC reduced> 5% CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344

Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Patient Education and Environmental Control at Each Step Step 1 Preferred: SABA prn Step 2 Preferred: Low-dose ICS Alternative: LTRA Cromolyn Theophylline Step 3 Preferred: Medium-dose ICS OR Low-dose ICS+ either LABA, LTRA, Theophylline Or Zileutin Step 4 Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+ either LTRA, Theophylline Or Zileutin Step 5 Preferred: High dose ICS + LABA AND Consider Omalizumab for patients with allergies Step 6 Preferred: High-dose ICS + LABA + oral Corticosteroid AND Consider Omalizumab for patients with allergies Assess Control STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS Step up if needed (check adherence, environmental control and comorbidities) Step down if possible (asthma well controlled for 3 months) EPR-3, p333-343

Asthma Control The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled.  Well Controlled  Not Well Controlled  Very Poorly Controlled

Classification of Asthma Control Components of Control ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS > 12 YEARS OF AGE AND ADULTS IMPAIRMENT RISK Recommended Action For Treatment Well Controlled Not Well Controlled Very Poorly Controlled Symptoms Nighttime awakenings Interference with normal activity SABA use FEV 1 or peak flow Validated questionnaires ATAQ/ACT Exacerbations Progressive loss of lung function Rx-related adverse effects Consider in overall assessment of risk Evaluation requires long-term follow up care 0- 1 per year 2 - 3 per year > 3 per year none Some limitation Extremely limited < 2 days/week > 2 days/week Throughout the day < 2/month 1-3/week > 4/week < 2 days/week > 2 days/week Several times/day > 80% predicted/ personal best 60-80% predicted/ personal best <60% predicted/ personal best 0/> 20 1-2/16-19 3-4/< 15 • Maintain current step • Consider step down if well controlled at least 3 months • Step up 1 step • Reevaluate in 2 - 6 weeks • Consider oral steroids • Step up (1-2 steps) and reevaluate in 2 weeks EPR-3, p77, 345

Current Therapy  Use Asthma Guidelines as a guide  Poor adherence with inhaled therapy  No curative therapy  Many patients remain poorly controlled  Recognition of different phenotypes of asthma

New/Upcoming Asthma Therapies  Recognition that there are different phenotypes or endotypes of asthma  Phenotype – observable characteristics or clinical presentation (e.g., transient vs. persistent wheezing)