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1. Occasional episodic or exercise-induced symptoms - inhaled short-acting beta-2 agonist, using a metered-dose inhaler (MDI) or equivalent

salbutamol MDI (100 µg per puff) 200 µg, prn $4.90/200 puffs

or pirbuterol (250 µg per puff) 500 µg, prn $10.00/300 puffs

or terbutaline Turbuhaler® (500 µg per puff) 500 µg, prn $14.30/200 puffs

2. If beta-2 agonists have to be used more than 3 times per week - inhaled corticosteroids, using an MDI or equivalent

triamcinolone MDI (200 µg per puff)

Adults and children 200 µg, tid to qid $0.20-0.27/day

or 400 µg, bid $0.27/day

or flunisolide MDI (250 µg per puff)

Adults and children 500 µg, bid $0.64/day

or beclomethasone MDI (50 or 250 µg per puff)

Adults 500-1000 µg/day, divided bid to qid $0.71-1.42/day (250 µg/puff inhaler)
Children 4-15 years 100 µg, bid to qid $0.08/day(50 µg/puff inhaler)

3. Long-acting beta-2 agonist as a replacement when regular use of short-acting
beta-2 agonists is required; also for those with nocturnal asthma. Not to be used for acute exacerbations

salmeterol MDI (25 µg per puff) 50 µg, bid $1.66/day

or formoterol Aerolizer ™ (12 µg per puff) 12 µg, bid $2.26/day

Second-line therapies:

1. As an alternative to inhaled corticosteroids for mild to moderate asthma, for the prevention of exercise-induced bronchospasm or before a provocative challenge known to exacerbate asthma

Adults and adolescents

sodium cromoglycate MDI (1 mg per puff) 2-4 mg, qid $1.58-3.16/day

or nedocromil sodium MDI (2 mg per puff) 4-8 mg, qid $1.84-3.68/day

Children (as an alternative to inhaled corticosteroids)

ketotifen

3-5 years 1 mg, bid $1.88/day

2. months to 2 years 0.05 mg/kg, bid $0.09/kg per day
i. During acute exacerbations and/or in addition to first-line agents especially in those with a combination of asthma and chronic obstructive pulmonary disease ipratropium MDI (20 µg per puff) 40 µg, qid $0.63/day

3. For primary therapy in cases in which the administration of an inhaled corticosteroid
even with an aerochamber is difficult or troublesome; primary therapy in any patient
judged more likely to adhere to a regimen of oral medication than an inhaled regimen; additive therapy for patients whose asthma is not adequately controlled with conventional doses of an inhaled corticosteroid.

theophylline, slow release

Adults 10 mg/kg per day, divided bid (maximum 300 mg/day); increase at 3-day intervals to16 mg/kg per day, divided bid (maximum 600 mg/day) $0.01-0.03/kg per day

Children 12-16 years 12 mg/kg per day, divided bid; increase at 3-day intervals to maximum of 16 mg/kg per day $0.01-0.02/kg per day

Children 9-11 years 12 mg/kg per day, divided bid; increase at 3-day intervals to maximum of 18 mg/kg per day $0.01-0.02/kg per day

Children 1-8 years 12 mg/kg per day, divided bid; increase at 3-day intervals to maximum of 20 mg/kg per day $0.01-0.02/kg per day

Children <1 year mg/kg per day = 0.2 x age in weeks + 5, divided bid $0.01/mL(5.3 mg/mL)

4. In mild persistent asthma when inhaled steroids are not tolerated

zafirlukast 20 mg, bid $1.40/day

5. For acute exacerbations

prednisone

Adults 50 mg, once daily x 10 days $1.00/10 days
Children 0.5-2 mg/kg per day, once daily x 10 days (maximum 50 mg/day) $0.50-2.10/kg for 10 days

Additional instructions and notes

-Inhaled beta-2 agonists may be used as frequently as 2 puffs q.i.d. Patients already taking inhaled corticosteroids and using beta-2 agonists more often may need additional medication and should be reassessed.

-In patients who are not well controlled on medium doses of inhaled corticosteroids, add either a long-acting inhaled beta-2 agonist or theophylline before initiating the long-term use of high-dose inhaled corticosteroids.

-Children should receive the same dose of inhaled beta-2 agonists as adults.

-Salbutamol syrup is no longer recommended, as nearly all children, even young infants, can be administered inhaled beta-2 agonists through an aerochamber.

-In mild asthma, there is no advantage to using beta-2 agonists on a regular schedule as opposed to "as-needed."

-The lowest dose of inhaled corticosteroids required to maintain good asthma control should be used.

-It is not necessary to taper prednisone if the patient is using inhaled corticosteroids.

-The full benefits of ketotifen may not be seen for 8-12 weeks; for sodium cromoglycate and nedocromil sodium 1-2 weeks of therapy may be necessary.

-In a primary care setting, prophylaxis for children aged 1-4 years with sodium cromoglycate was no more effective than placebo.

-If patients are unable to use an MDI properly due to coordination problems, consider an aerochamber or alternative delivery method, e.g., diskhaler or rotocaps. Use of an aerochamber may decrease both local and systemic adverse effects of inhaled corticosteroids. Large-volume aerochambers are preferable to small-volume ones. Doses of beta-2 agonists and inhaled corticosteroids may vary depending on the delivery method.

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