Asthma: Diagnosis and Management ____________________________________________________________
STEPWISE APPROACH FOR MANAGING ASTHMA IN PATIENTS 0 TO 4 YEARS OF AGE
Treatment Step
Preferred Treatment
Alternative Treatment
Considerations
Step 1
SABA AND
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Use SABA as needed for symptoms in any step (as indicated), up to three treatments at 20-minute intervals depending on severity of symptoms. Caution: Increasing use of SABA or use >2 days a week for symptom relief generally indicates inadequate control and may require a step up in treatment. Consider short course of oral systemic corticosteroid if exacerbation is severe or individual has history of previous severe exacerbations.
At the start of respiratory tract infection, add a short course of ICS
Daily low-dose ICS and SABA Daily cromolyn a ; or
Step 2
montelukast a ; and SABA
Step 3
Daily medium-dose ICS and SABA Daily medium-dose ICS/ LABA and SABA Daily high-dose ICS/LABA and SABA Daily high-dose ICS/LABA + oral systemic corticosteroid and SABA
—
For children 4 years of age only, see Step 3 and Step 4 in Table 5
Step 4
Daily medium-dose ICS + montelukast a and SABA Daily high-dose ICS + oral montelukast a and SABA Daily high-dose ICS + montelukast a + oral systemic corticosteroid and SABA
Step 5
Step 6
Steps 1–6 In each step, assess environmental factors, provide patient education, and manage comorbidities, then: Step up if needed; reassess in 2 to 6 weeks Step down if possible (if asthma is well controlled for at least 3 consecutive months) ICS=inhaled corticosteroid; LABA=long-acting beta2-agonist; LAMA=long-acting muscarinic antagonist; LTRA=leukotriene receptor antagonist; SABA=inhaled short-acting beta2-agonist a Cromolyn and montelukast were not considered in the 2022 update of the NAEPP guidelines, have limited availability for use in the United States, and/or have an increased risk of adverse consequences and need for monitoring that make their use less desirable. The FDA issued a boxed warning for montelukast in March 2020 due to the risk for serious neuropsychiatric events, including suicide. Source: [9; 10] Table 4
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MDVT1726
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