Asthma Treatment & Management

For all but the most severely affected asthma patients, the ultimate goals of treatment are to prevent symptoms, minimize morbidity from acute episodes, and prevent functional and psychological morbidity so as to provide a healthy (or near-healthy) lifestyle appropriate to the age of the patient. Medical care involves both treatment of acute asthmatic episodes and control of chronic symptoms, including those of nocturnal asthma and exercise-induced bronchoconstriction (EIB; also referred to as exercise-induced asthma [EIA]).

Environmental control is an important component of management. Pharmacologic management includes the use of control agents such as inhaled corticosteroids (ICSs), long-acting beta₂ agonists (LABAs) and muscarinic antagonists (LAMAs; also referred to as anticholinergics), theophylline, and leukotriene modifiers, as well as more recent strategies such as the use of antibodies to immunoglobulin E (IgE; eg, omalizumab) and antibodies to interleukin (IL)-5, IL-4, and IL-13 in selected patients. Relief medications include short-acting beta₂ agonists (SABAs) and muscarinic antagonists (SAMAs), systemic corticosteroids, and ipratropium.

Guidelines from the National Asthma Education and Prevention Program (NAEPP) ^[5] and the Global Initiative for Asthma (GINA) ^[32] have outlined stepwise approaches to asthma management (step up if necessary, step down when possible) that follow different paths, depending on patient age or medication use. The intensity of treatment depends on the severity of symptoms.

In general, patients should be assessed every 1-6 months for asthma control. At every visit, adherence, environmental control, and comorbid conditions should be checked. If a patient has good control of her or his asthma for at least 3 months, treatment can be stepped down; however, the patient should be reassessed in 2-4 weeks to make sure that control is maintained with the new treatment.

Guideline recommendations

Pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change.

National Asthma Education and Prevention Program

The 2020 NAEPP guidelines described a six-step approach that follows one of three paths, defined by patient age (0-4 y, 5-11 y, or ≥12 y). ^[5] The following are recommendations for use of controller and reliever medications in adults with asthma:

• Step 1 (intermittent asthma) — Controller medication not indicated; reliever medication is a SABA as needed for symptoms
• Step 2 (mild persistent asthma) — Preferred controller medication is a low-dose ICS; alternatives include cromolyn, an LTRA, or theophylline
• Step 3 (moderate persistent asthma) — Preferred controller medication is either a low-dose ICS plus a LABA (combination therapy) or a medium-dose ICS
• Step 4 (moderate-to-severe persistent asthma) — Preferred controller medication is a medium-dose ICS plus a LABA
• Step 5 (severe persistent asthma) — Preferred controller medication is a high-dose ICS plus a LABA
• Step 6 (severe persistent asthma) — Preferred controller medication is a high-dose ICS plus a LABA plus an oral corticosteroid

Global Initiative for Asthma

The 2025 GINA guidelines described a five-step approach that can take two tracks, depending on the choice of asthma medications (preferred or alternative). ^[32] The track 1 (preferred) management approach to asthma in patients aged 12 years or older includes the following steps:

• Step 1-2 — Low-dose ICS-formoterol as needed
• Step 3 — Low-dose ICS-formoterol daily for maintenance and relief
• Step 4 — Medium-dose ICS-formoterol daily for maintenance and relief
• Step 5 — Add-on LAMA; refer for phenotype assessment; consider anti–IgE, anti–IL-5/5R, anti–IL-4Rα, anti–TSLP

European Respiratory Society / American Thoracic Society

The 2020 joint ERS/ATS guidelines included additional recommendations for treatment of severe asthma, including therapeutic trials of omalizumab for severe allergic asthma and avoidance of methotrexate or macrolide antibiotics. ^[46]

Environmental exposures and irritants can play a strong role in symptom exacerbations. Accordingly, in patients who have persistent asthma, the use of skin testing or in-vitro testing to assess sensitivity to perennial indoor allergens is important. Once the offending allergens are identified, patients should be counseled on avoidance from these exposures. In addition, they should be provided with education regarding avoidance of tobacco smoke (both first-hand and second-hand exposure).

Allergen avoidance takes different forms, depending on the size and characteristics of the specific allergen. Improvement in symptoms after avoidance of the allergen should result rather rapidly, though the allergen itself (eg, cat dander) may linger in the environment for months after primary removal of the source. Individual interventions are rarely successful by themselves; thus, a multifaceted approach is necessary.

Home-related factors

Efforts should focus on the home, where 30-60% of time is spent. Patients should clean and dust their homes regularly. ^[77] If vacuuming cannot be avoided, it should be done with a face mask in place or with a double-bagged vacuum that has a high-efficiency particulate air (HEPA) filter.

Specific factors related to the home include dust mites, animals, cockroaches, mold, and pollen.

Dust mites

In the case of dust mites (Dermatophagoides pteronyssinus and farinae), the primary allergen is an intestinal enzyme on fecal particles. Measures to avoid dust mites include using impervious covers on mattresses, pillows, and comforters; washing bedding in hot water; removing rugs from the bedroom; and reducing room humidity to <50%.

Animals

Because of the small size (1-20 μm) of dander, saliva, urine, or serum proteins of cats and other animals, these allergens are predominantly airborne. Avoidance involves removing animals from the home, using dense filtering material over heating and cooling duct vents, and washing cats and dogs as often as twice weekly.

Air pollution

Air pollution caused by traffic may increase the risk of asthma and wheezing, especially in individuals with EPHX1 gene and enzyme activity. ^[79] This can be mediated through airway oxidative stress generation.

Asthma medications are generally divided into two categories:

• Quick relief (also called reliever medications)
• Long-term control (also called controller medications)

Quick relief

Reliever medications are used to alleviate acute asthma exacerbations and to prevent EIB symptoms. These medications include SABAs, anticholinergics (used only for severe exacerbations), and systemic corticosteroids, which speed recovery from acute exacerbations.

Long-term control

Long-term controller medications include ICSs, ^[80,81] LABAs, LAMAs, ICS-LABA combinations, methylxanthines, and LTRAs. ICSs are considered the primary drugs of choice for control of chronic asthma, but unfortunately, the response to this treatment is characterized by wide variability among patients. A study by Tantisira et al showed the glucocorticoid-induced transcript 1 gene (GLCCI1) to be the cause of this decrease in response. ^[82]

Omalizumab

Omalizumab is a humanized murine IgG antibody against the Fc component of the IgE antibody. Use of this antibody prevents IgE from binding directly to the mast cell receptor, thereby preventing cell degranulation. It is indicated for adults and children aged 6 years or older with moderate-to-severe persistent asthma who have a positive skin test result for a perennial aeroallergen and whose symptoms are inadequately controlled with ICSs.

Mepolizumab

Mepolizumab is a humanized IgG1 kappa monoclonal antibody specific for IL-5. It is approved for add-on maintenance treatment of patients with severe asthma aged 6 years or older and with an eosinophilic phenotype. Administered SC at 100 mg every 4 weeks in adolescents and adults. ^[89-91]

Benralizumab

Benralizumab is an IL-5 receptor alpha-directed cytolytic monoclonal antibody. It reduces eosinophils and basophils through antibody-dependent cell-mediated cytotoxicity and is approved for add-on maintenance treatment of severe asthma in patients aged 6 years or older with an eosinophilic phenotype. ^[94-96]

Dupilumab

Dupilumab is a human monoclonal antibody that binds to the alpha subunit of the IL-4 receptor and inhibits the activity of both IL-4 and IL-13. It is FDA-approved as add-on maintenance treatment for patients with moderate-to-severe asthma with an eosinophilic phenotype. ^[97,98]

Tezepelumab

Tezepelumab is a first-in-class human IgG2 lambda monoclonal antibody that inhibits TSLP. It is FDA-approved as add-on maintenance treatment for severe asthma in adults and adolescents aged 12 years or older at a standard dosage of 210 mg SC every 4 weeks. ^[99,100]

Depemokimab

Depemokimab is a monoclonal antibody that inhibits IL-5. In December 2025, it was approved by the FDA for use in patients with severe asthma and an eosinophilic phenotype. The dosage is 100 mg SC every 6 months in adolescents and adults. ^[101]

The use of immunotherapy for the treatment of asthma has been controversial. A meta-analysis of 88 RCTs confirmed efficacy in asthma. ^[102] The NAEPP Expert Panel Report recommended that immunotherapy be considered if a clear relationship exists between symptoms and exposure to an unavoidable allergen, symptoms occur all year or during a major portion of the year, and symptoms are difficult to control with pharmacologic management.

Subcutaneous immunotherapy (SCIT) has been shown to yield improved medical outcomes and cost savings compared with symptomatic therapy alone. Sublingual immunotherapy (SLIT) has also been shown to improve allergic rhinitis symptoms and is widely used in European, South American, and Asian countries.