Richard Beasley, Irene Braithwaite, Alex Semprini, Ciléin Kearns, Mark Weatherall, Tim W. Harrison, Alberto Papi, Ian D. Pavord
European Respiratory Journal 2020 55: 1901407;
A stepwise approach to the pharmacological treatment of asthma is a key feature of current asthma guidelines. Through algorithms, treatment intensity is “stepped up” to obtain asthma control and reduce the risk of exacerbations, and “stepped down” after a period of prolonged control and absence of exacerbations. Traditional algorithms advocated short-acting β2-agonist (SABA) reliever therapy for all levels of severity, initially as sole therapy at Step 1, together with maintenance “low dose” inhaled corticosteroids (ICS) at Step 2, with maintenance ICS/long-acting β2-agonist (LABA) at “low”, “moderate” or “high” doses at Steps 3 and 4, and finally with “add-on” therapies at Step 5.
In a paradigm shift in the stepwise approach, the 2019 update of the GINA guidelines now recommends ICS/formoterol reliever therapy as the preferred reliever option across all steps of the treatment algorithm . This proposition is based on strong evidence that ICS/formoterol reliever therapy is more effective and safer than SABA reliever therapy for all levels of asthma severity , as summarised in figure 1. ICS/formoterol reliever therapy can be defined as “anti-inflammatory reliever therapy”, a terminology that probably also applies to combined ICS/SABA reliever therapy, which is more effective at reducing exacerbations than SABA reliever therapy alone.