Moderate Persistent Asthma

Aka: Moderate Persistent Asthma, Moderate Asthma

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II. Criteria

  1. Moderate limitation with normal activity
  2. Daily symptoms
    1. Daily Beta Agonist use
    2. Daily symptoms
    3. Nocturnal symptoms more than once per week (but not nightly)
      1. For age <5 years, 3-4 night awakenings per month
  3. Pulmonary Function Tests
    1. FEV1 or PEF between 60-80% predicted
    2. FEV1 to FVC Ratio decreased 5% (75-80% for age 5-19, 70-75% for age 20-39, 65-70% for age 40-59, then 60-65%)
    3. PEF variability >30%

III. Management

  1. See Asthma Stepped Care
  2. See Asthma Education
  3. See Breathing Exercises in Asthma
  4. Long-acting (use both agents)
    1. Long-Acting Beta Agonists (LABA, e.g. Salmeterol, Formoterol)
      1. Consider weaning off in well controlled Moderate Asthma (see below)
      2. Formoterol when used as maintenance, may be used as rescue Inhaler as well (2020 Asthma guidelines)
        1. See Single Maintenance and Reliever Therapy (SMART Asthma Management Protocol)
    2. Inhaled Corticosteroids
      1. Start with medium dose Corticosteroid when stepping up to combine with long-acting Bronchodilator
        1. May decrease to a low-dose Corticosteroid once Asthma well controlled
      2. Avoid eliminating Corticosteroid completely
        1. Associated with poorer outcomes
        2. Lemanske (2001) JAMA 285:2594-603 [PubMed]
  5. Short-acting
    1. Rescue with beta Agonist
  6. Adjunctive agents: Leukotriene agents
    1. Leukotriene Receptor Antagonist (e.g. Montelukast)
      1. Risk of Major Depression and Suicide
    2. Leukotriene Synthesis Inhibitors (e.g. Zileuton or Zyflo)
  7. Exacerbations
    1. See Asthma Exacerbation
    2. See Asthma Exacerbation Home Management
    3. See Emergency Management of Asthma Exacerbation
    4. See Asthma Inpatient Management
    5. See Status Asthmaticus
    6. See Asthma Exacerbation Severity Evaluation
    7. See Asthma-Related Death Risk Factors

IV. Management: Stepping down therapy in well controlled Moderate Asthma

  1. Indications
    1. Albuterol rescue Inhaler use no more than 2 times weekly while on combination long-acting agents
  2. Protocol
    1. Step 1
      1. Decrease dose of Inhaled Corticosteroid
      2. Continue the long-acting Bronchodilator
    2. Step 2
      1. Continue the Inhaled Corticosteroid at either low dose (or at increased dose)
      2. Stop the long-acting Bronchodilator (e.g. Salmeterol or Serevent)
    3. Step 3
      1. Restart the long-acting Bronchodilator if Albuterol rescue Inhaler required more than 2 times weekly
  3. References
    1. (2012) Presc Lett 19(11): 62

V. Prevention

  1. See Asthma Education
  2. Influenza Vaccine
  3. Weight loss in Obesity
  4. Regular Physical Exercise

VI. References

  1. Park (2017) Asthma Updates, Mayo Clinical Reviews, Rochester, MN
  2. (1997) Management of Asthma, NIH 97-4053
  3. (1995) Global Strategy for Asthma, NIH 95-3659
  4. Kalister (2001) West J Med 174:415-20 [PubMed]
  5. Kemp (2001) Am Fam Physician 63(7):1341-54 [PubMed]
  6. Pollart (2009) Am Fam Physician 79(9):761-7 [PubMed]

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