Master Stages of Asthma Treatments with Picmonic for Physician Assistant

Inhaled short-acting beta-agonists (SABA), such as albuterol, are the mainstay treatment for intermittent asthma, and symptoms are entirely resolved with their use. The onset of action of SABAs is between 1 and 5 minutes, and the duration is between 4 and 6 hours. They cause bronchodilation by stimulating beta-2 adrenergic receptors.

Mild persistent asthma requires advancement to step 2 on the asthma management protocol. In addition to a rescue inhaler (short-acting beta agonist), daily low-dose inhaled glucocorticoids, such as budesonide or beclomethasone, are commonly used to control inflammation in patients with persistent asthma.

Leukotrienes are chemical mediators of the allergic response and are overactive in asthma. The leukotriene receptor antagonists (LTRA), montelukast and zafirlukast, block leukotriene receptors, which decreases bronchoconstriction, hypersecretion, and eosinophil recruitment. Daily LTRA therapy combined with SABA rescue therapy can be used.

Moderate persistent asthma requires advancement to step 3 in the asthma management protocol. Step 3 involves increasing to medium-dose inhaled corticosteroids (Budesonide) daily for airway inflammation management, in addition to the use of a short-acting beta agonist as needed.

Zileuton acts on the front end of the leukotriene pathway through inhibition of the 5-lipoxygenase enzyme, which is involved in the production of leukotrienes.

Step 4 of the protocol calls for escalation to medium- to high-dose inhaled corticosteroids in combination with a long-acting beta-agonist (LABA) and a long-acting muscarinic agonist (LAMA). Leukotriene receptor antagonists can also be used.

Some patients with severe asthma may require systemic corticosteroids to control their airway inflammation. Although corticosteroids are the most potent and effective for asthma control, they have serious side effects when used for an extended period of time. To avoid cushingoid side effects, the lowest effective dose should be used. They can be administered in short bursts to control exacerbations, or in low daily doses to patients who experience frequent, severe exacerbations.

Omalizumab is an anti-IgE monoclonal antibody that can be used in severe cases of "allergic asthma" or asthma that is driven by an IgE response. This can be determined with high blood IgE levels or positive allergen skin testing. Omalizumab is administered subcutaneously every 2 to 4 weeks.