Stepwise Approach in Asthma Revisited 2023: Expert Panel Opinion of Turkish Guideline of Asthma Diagnosis and Management Group

Abstract

Introduction of inhaled corticosteroids (ICS) has been the cornerstone of the long-term management of asthma. ICSs either alone or in combination with long-acting beta-2 agonists have been shown to be associated with favorable asthma outcomes. However, asthma control is still reported to be below expectations all around the world. Research in the last decades focusing on the use of ICS/formoterol both as maintenance and as needed (maintenance and reliever therapy approach) showed improved asthma outcomes. As a result of recent developments, Turkish Asthma Guidelines group aimed to revise asthma treatment recommendations. In general, we recommend physicians to consider the risk factors for poor asthma outcomes, patients' compliance and expectations and then to determine "a personalized treatment plan." Importantly, the use of short-acting beta-2 agonists alone as a symptom reliever in asthma patients not using regular ICS is no longer recommended. In stepwise treatment approach, we primarily recommend to use ICS-based controllers and initiate ICS as soon as possible. We define 2 different treatment tracks in stepwise approaches as maintenance and reliever therapy or fixed-dose therapy and equally recommend each track depending on the patient's risks as well as decision of physicians in a personalized manner. For both tracks, a strong recommendation was made in favor of using add-on treatments before initiating phenotype-specific treatment in step 5. A strong recommendation was also made in favor of using biologic agents and/or aspirin treatment after desensitization in severe asthma when indicated.

Figure 1.

Risk factors for poor prognosis of asthma. FEV1, forced expiratory volume in the first second of expiration; ICS, inhaled corticosteroid; OCS, oral corticosteroid; P450, cytochrome P450; SABA, short-acting beta-2 agonist.

Figure 2.

General treatment strategies for adjusting chronic follow-up of asthma.

Figure 3.

Stepwise approach for chronic treatment of asthma based on treatment tracks. ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonist; LAMA, long-acting muscarinic antagonists; LTRA, leukotriene receptor antagonist; OCS, oral corticosteroid; SABA, short-acting beta-2 agonist.

Figure 4.

Monitoring parameters of asthma at initial diagnosis and follow-up. ACT, asthma control test; FEV1, forced expiratory volume in the first second of expiration; FVC, forced vital capacity; GINA, Global Initiative for Asthma.

Figure 5.

Approach to patient whose asthma is not well controlled under treatment. ACT, asthma control test; GINA, Global Initiative for Asthma.^*ACT < 20 or presence of GINA 3-4 criteria. ^**See text.

Figure 6.

Approach to stepping down treatment. ACT, asthma control test; GINA, Global Initiative for Asthma. ^*ACT = 25 OR none of the GINA criteria exist. ^**According to the case and the physician’s decision, it can be continued at the same step for up to 6 months.

Figure 7.

Step-up and step-down based on tracks. BUD, budesonide; FOR, formoterol; ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonist; SABA, short-acting beta-2 agonist. ^*See Table 5. ^**See Figure 3.

Figure 8.

Problems and barriers in Turkey and recommendations provided by expert panel [recommendations 1-9]. ICS, inhaled corticosteroid; LTRA, leukotriene receptor antagonist; MART, maintenance and reliever therapy; OCS, oral corticosteroid; SABA, short-acting beta-2 agonist.