Asthma is a common chronic respiratory condition. Step-up therapy is an asthma treatment method that aims to control symptoms by starting with a low dose of medication and increasing it as needed.
Because asthma is a chronic condition, treatment focuses on managing a person’s symptoms.
First, a doctor will diagnose and assess the severity of a person’s asthma. Then, they will decide where to start them in step-up therapy.
Asthma step-up therapy includes regular follow-up appointments. This allows the doctor to evaluate how an individual is responding to treatment
After a person’s symptoms are consistently under control for a specific amount of time, the doctor may begin a step-down method. This reduces medication intensity while still managing symptoms.
Read more to learn about asthma step-up therapy, asthma management strategies, and more.
Asthma step-up therapy is a stepwise method of treating symptoms. It involves gradually increasing a person’s asthma medication until they reach the right amount to control their symptoms.
When starting asthma step-up therapy, a doctor will first evaluate a person’s asthma symptoms and determine their severity. Then, they will prescribe medication –– typically the lowest possible dose. They will assess the individual’s symptoms every two to four weeks and adjust their medication dosage accordingly.
The goal of step-up therapy is to reach a medication dosage that allows the person to sleep well at night, avoid emergency room visits and hospitalizations, and live their life without asthma complications.
Sometimes, a doctor might decrease –– or “step down” –– a person’s medication dosage. Starting with a higher dose and working their way down can help people who have severe asthma symptoms.
The Global Initiative for Asthma (GINA) outlines recommendations for step-up therapy in the Global Strategy for Asthma Management and Prevention.
The following sections outline GINA’s step-up and step-down recommendations for people 12 years old and older.
While the report does make step-up and step-down recommendations for younger children with asthma, the medications and dosages can vary. It should also be noted that these are merely guidelines, and individuals should contact a doctor to discuss the best treatment for their asthma.
Diagnosis
First, a person will be diagnosed with asthma. If they already have a diagnosis, a doctor or allergist will confirm it.
A healthcare professional will consider several factors when diagnosing asthma, including:
- a person’s symptoms, personal medical history, and family medical history
- a physical exam focusing on the skin, chest, and upper respiratory tract
- various tests, including a lung function test
Assess severity
Once the person has a diagnosis, the doctor will assess the severity of their asthma.
Generally, this involves looking at how a person’s lungs function and how often they have asthma symptoms.
A doctor will consider whether a person has symptoms:
- fewer than twice a month
- most days, or if they wake up at night at least once a week
- every day, waking up at least once a week, and low lung function
Assessing severity tells the doctor where to begin treatment. It also provides a benchmark to compare a person’s symptoms to in the future.
Initiate medication
GINA outlines two “tracks” for starting asthma medication.
Both tracks include controller medication, which is a long-term medicine for asthma maintenance, and reliever medication, which is a fast-acting medicine for quick symptom relief. The main difference between the two tracks is the type of reliever medication used.
Each track includes five steps. Typically, step one starts with the lowest appropriate dosage. Each successive step gradually increases the dosage, and some later steps include additional medications for symptom relief. A person’s doctor may choose to add other medications, too.
Track one
This track includes a controller for long-term relief as an inhaled corticosteroid (ICS). Steps 1–4 gradually increase the ICS dosage. People on this track can use a low-dose reliever medication for fast-acting relief as needed.
Step 5 introduces a long-acting muscarinic antagonist (LAMA) as an add-on medication.
Track two
This track also includes a controller medication. For a reliever, it has a short-acting beta-antagonist (SABA).
Step 3 introduces a long-acting beta-antagonist (LABA), and step 5 introduces a LAMA as an add-on medication.
Action plan
Additionally, the doctor might create an asthma action plan. This plan outlines what a person should do if they have worsening symptoms or an asthma attack. It tells a person what medications they should take, the dosages they should use, and signs they should seek medical attention.
Learn more about asthma action plans.
Follow ups
Follow-up appointments are an essential part of successful asthma step-up therapy.
GINA encourages specialists to schedule a follow-up appointment 1-3 months after the person begins step-up therapy, and every 3-12 months after that. However, the frequency of a person’s follow-up appointments will depend on factors such as their initial control level, how they respond to treatment, and how engaged they are in managing their asthma.
A person’s doctor will perform blood tests and lab work to determine which subtype of asthma a person has. This is called endotyping.
Once they have determined what kind of asthma an individual has, they can use additional treatments. These can include biologic injectable therapy. This is a type of therapy that improves asthma symptoms and prevents attacks by stopping the body processes that cause the lungs to be inflamed.
Aside from following asthma step-up therapy, there are several other ways people can manage their asthma.
One of the most common ways is to avoid asthma triggers. Common triggers include:
- allergens like dust mites, animal dander, and pollen
- tobacco smoke
- weather changes
- exercise
- certain medications
- anxiety and stress
Other management strategies are specific to the person with asthma.
For example, pregnant individuals may benefit from a multi-faceted approach to asthma management. A
These teams may include obstetricians, allergists, nurses, pulmonary specialists, and asthma educators working together for the health of both mother and baby.
Additionally, people who have asthma and other health conditions may consider working with a specialist and allergist. This will give them a tailored management plan that takes their various health needs into account.
For example, obesity is a common comorbid –– or co-occurring –– condition among people with asthma.
Obesity may exacerbate asthma symptoms as well as make symptoms more difficult to treat. One 2018 study suggests people with asthma and obesity may experience better symptom management if they treat insulin resistance alongside asthma, especially in people who also have diabetes.
Additionally, some research points to the potential benefit of developing a healthy weight loss plan with a doctor.
People with asthma can take action to reduce its impact on their daily lives. Some steps people can take include:
- sticking with their asthma treatment and management plans
- contacting their doctors when symptoms worsen or medication stops working
- eating a nutritious diet and exercising regularly (people with exercise-induced asthma should discuss safe exercise options with a doctor)
- creating asthma-friendly environments at home, work, and school by removing potential triggers
- finding a support group
Asthma step-up therapy is a stepwise method of asthma management. First, a doctor or allergist diagnoses a person’s asthma and assesses the severity. They will prescribe a low dosage of medication and gradually increase it until the person achieves symptom control.
After starting asthma step-up therapy, the person will regularly meet with their doctor for follow-up appointments.
People can also manage their asthma by avoiding triggers, adhering to their treatment plan, and contacting their doctor when symptoms flare up.