Nota Medik
Asthma in Adults: Relievers, Inhaler Doses, ICS Levels & Exacerbation Drugs
Contents
- Relievers and maintenance
- Low, medium and high ICS doses
- Doses of common asthma medications
- A. Inhaled short-acting β2-agonists (SABA)
- B. Inhaled corticosteroids (ICS)
- C. ICS/LABA combination
- D. Long-acting muscarinic antagonists (LAMA)
- E. ICS/LABA/LAMA
- F. Leukotriene receptor antagonists (LTRA)
- G. Methylxanthine
- H. Nebuliser
- Asthma exacerbation
- Sources
The drugs of the CPG Management of Asthma in Adults (Second Edition, 2024) in one place: what the CPG recommends for relievers and maintenance, how it grades ICS doses, the dose of each inhaler it lists, and what to give in an exacerbation. Recommendations, tables and doses are copied word for word from the CPG (© MaHTAS, Ministry of Health Malaysia). The same doses are on Drugs.
Relievers and maintenance
Recommendation 2
- The assessment of asthma control should be performed before considering stepping up or down the treatment algorithm.
- Short-acting β2-agonist should always be taken together with inhaled corticosteroids.
- Treatment should be stepped up to achieve good asthma control.
- If good asthma control is achieved at 3 – 6 months re-assessment, consider stepping down treatment to find the lowest effective dose.
Recommendation 5
- In the treatment of asthma:
- inhaled short-acting β2-agonists (SABA) should not be used as monotherapy
- inhaled SABA may be used as reliever therapy with regular inhaled corticosteroids (ICS)
- inhaled SABA overuse (≥3 canisters/year) should be avoided
- oral SABA should not be used
- anti-inflammatory reliever (AIR) therapy (either ICS with formoterol or ICS with SABA) may be used as a reliever therapy
- inhaled long-acting β2-agonists (LABA) without ICS should not be used as reliever monotherapy
Recommendation 6
- All asthma patients should be on inhaled corticosteroids (ICS)- containing therapy.
- Combination of ICS/long-acting β2-agonist (LABA) is preferred to high-dose ICS during stepping-up of asthma treatment.
- In moderate to severe asthma, either low-to-medium-dose maintenance and reliever therapy (MART) or high-dose ICS/LABA plus as-needed SABA may be used.
- Triple therapy (ICS/LABA/long-acting muscarinic antagonist) should be used in patients with uncontrolled asthma despite treatment with medium-to-high-dose ICS/LABA.
- Theophylline should not be used for treatment of asthma.
Low, medium and high ICS doses
Table 7 of the CPG, total daily dose in µg:
| Inhaled corticosteroids (alone or in combination with LABA) | Total daily ICS dose (µg) | ||
|---|---|---|---|
| Low | Medium | High | |
| Beclometasone dipropionate (pMDI, standard particle, HFA) | 200 - 500 | >500 - 1000 | >1000 |
| Beclometasone dipropionate (DPI or pMDI, extrafine particle, HFA) | 100 - 200 | >200 - 400 | >400 |
| Budesonide (DPI, or pMDI, standard particle, HFA) | 200 - 400 | >400 - 800 | >800 |
| Ciclesonide (pMDI, extrafine particle, HFA) | 80 - 160 | >160 - 320 | >320 |
| Fluticasone furoate (DPI) | 100 | 200 | |
| Fluticasone propionate (DPI) | 100 - 250 | >250 - 500 | >500 |
| Fluticasone propionate (pMDI, standard particle, HFA) | 100 - 250 | >250 - 500 | >500 |
| Mometasone furoate (DPI) | Depends on DPI device - refer to product information | ||
| Mometasone furoate (pMDI, standard particle, HFA) | 200 - 400 | >400 | |
Source: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2024. Updated May 2024 (Available at: www.ginasthma.org)
Doses of common asthma medications
Appendix 9 of the CPG, drug by drug (the adverse reactions column is left out here).
A. Inhaled short-acting β2-agonists (SABA)
| Drug | Dosage | Comments |
|---|---|---|
| Salbutamol 100 µg/dose inhaler, pMDI | • For relief of acute bronchospasm, 1 to 2 inhalations | • Reliever therapy |
| Salbutamol 100 and 200 µg/dose inhaler, Easyhaler® (DPI) | • For relief of acute bronchospasm, 1 inhalation as a single starting dose; may be increased to 2 inhalations if necessary | • Reliever therapy |
B. Inhaled corticosteroids (ICS)
| Drug | Dosage | Comments |
|---|---|---|
| Beclometasone dipropionate 50, 100 and 200 µg/dose inhaler, pMDI | Extra-fine formulation: • 50 - 200 µg twice/day; increase if necessary up to 400 µg twice/day (maximum daily dose: 800 µg) | • Maintenance therapy |
| Beclometasone dipropionate 200 µg/dose inhaler, Easyhaler® (DPI) | • 200 to 400 µg twice/day | • Maintenance therapy |
| Budesonide 100 and 200 µg/dose inhaler, pMDI | • 100 - 800 µg twice/day | • Maintenance therapy |
| Budesonide 100 and 200 µg/dose inhaler, Easyhaler® (DPI) | • 100 - 800 µg twice/day • Once/day dosing may be considered for mild to moderate asthma who are ICS-naïve (200 to 400 µg) or previously controlled on twice/day dose (up to 800 µg) | • Maintenance therapy |
| Budesonide 100 and 200 µg/dose inhaler, Turbuhaler® (DPI) | • 100 - 800 µg twice/day • Once/day dosing may be considered for mild to moderate asthma who are ICS-naïve (200 to 400 µg) or previously controlled on twice/day dose (up to 800 µg) | • Maintenance therapy |
| Ciclesonide 80 and 160 µg/dose inhaler, pMDI | • 160 µg once/day; in severe asthma, a higher dose of up to 640 µg/day (given as 320 µg twice/day) may be used | • Maintenance therapy |
| Fluticasone propionate 50 and 125 µg/dose inhaler, pMDI | • 100 - 1000 µg twice/day Starting doses: • 100 µg twice/day (mild asthma) • 250 - 500 µg twice/day (moderate and moderate to severe asthma) • Up to 1000 µg twice/day may be used where additional clinical benefit is expected | • Maintenance therapy |
C. ICS/LABA combination
| Drug | Dosage | Comments |
|---|---|---|
| Beclometasone dipropionate 100 µg and formoterol 6 µg inhaler, pMDI | Maintenance therapy: • 1 to 2 inhalations twice/day (maximum: 4 inhalations/day) Maintenance and reliever therapy (MART): • Maintenance dose: 1 inhalation twice/day with additional 1 inhalation as needed in response to symptoms • If symptoms persist after a few minutes, an additional inhalation should be taken • Maximum daily dose: 8 inhalations (allow up to 12 based on GINA) | • Maintenance therapy (can be used as single inhaler for MART) |
| Beclometasone dipropionate 100 µg and formoterol 6 µg inhaler, Nexthaler®, DPI | Maintenance therapy: • 1 to 2 inhalations twice/day (maximum: 4 inhalations/day) MART: • Maintenance dose: 1 inhalation twice/day with additional 1 inhalation as needed in response to symptoms • If symptoms persist after a few minutes, an additional inhalation should be taken • Maximum daily dose: 8 inhalations (allow up to 12 based on GINA) | • Maintenance therapy (can be used as single inhaler for MART) |
| Budesonide 160 µg and formoterol 4.5 µg inhaler, Turbuhaler® (DPI) | Anti-inflammatory reliever therapy (Mild asthma): One inhalation as needed in response to symptoms. If symptoms persist after [...] should be taken. Not more than 6 inhalations should be taken on any single occasion. A total daily dose of >8 inhalations is not normally needed; however, a total daily dose of up to 12 inhalations could be used for a limited period. If patients find the treatment less effective or need more inhalations than usual, medical attention must be sought. Maintenance therapy: • 1 to 2 inhalations twice/day. Some patients may require up to a maximum of 4 inhalations twice/day Maintenance and reliever therapy: • 2 inhalations/day, given either as one inhalation in the morning and evening or as 2 inhalations in either the morning or evening • For some patients, a maintenance dose of 2 inhalations twice/day may be appropriate • Patient should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion • A total daily dose of >8 inhalations is not normally needed; however, a total daily dose of up to 12 inhalations could be used for a limited period. Patients using >8 inhalations/day are strongly recommended to seek medical advice. | • Maintenance therapy (can be used as single inhaler for MART) |
| Budesonide 320 µg and formoterol 9 µg inhaler, Turbuhaler® (DPI) | • 1 inhalation twice/day • Some patients may require up to a maximum of 2 inhalations twice/day | • Maintenance therapy |
| Budesonide 80 µg and formoterol 4.5 µg inhaler, pMDI | • 2 inhalations once or twice/day (max: 4 inhalations twice/day) | • Maintenance therapy |
| Budesonide 160 µg and formoterol 4.5 µg inhaler, pMDI | • 2 inhalations once or twice/day (max: 4 inhalations twice/day) | • Maintenance therapy |
| Fluticasone furoate 100 µg and vilanterol 25 µg inhaler, Ellipta® (DPI) | • 1 inhalation once/day | • Maintenance therapy |
| Fluticasone furoate 200 µg and vilanterol 25 µg inhaler, Ellipta® (DPI) | • 1 inhalation once/day | • Maintenance therapy |
| Salmeterol 25 µg and fluticasone propionate 50 µg inhaler, pMDI | • 2 inhalations twice/day | • Maintenance therapy |
| Salmeterol 25 µg and fluticasone propionate 125 µg inhaler, pMDI | • 2 inhalations twice/day | • Maintenance therapy |
| Salmeterol 25 µg and fluticasone propionate 250 µg inhaler, pMDI | • 2 inhalations twice/day | • Maintenance therapy |
| Salmeterol 50 µg and fluticasone propionate 100 µg inhaler, Accuhaler® (DPI) | • 1 inhalation twice/day | • Maintenance therapy |
| Salmeterol 50 µg and fluticasone propionate 250 µg inhaler, Accuhaler® (DPI) | • 1 inhalation twice/day | • Maintenance therapy |
| Salmeterol 50 µg and fluticasone propionate 500 µg inhaler, Accuhaler® (DPI) | • 1 inhalation twice/day | • Maintenance therapy |
| Indacaterol acetate 150 µg, mometasone furoate 80 µg inhalation powder cap, Breezhaler (DPI) | • 1 cap once daily inhalation at same time each day | • Maintenance therapy |
| Indacaterol acetate 150 µg, mometasone furoate 160 µg inhalation powder cap, Breezhaler (DPI) | • 1 cap once daily inhalation at same time each day | • Maintenance therapy |
| Indacaterol acetate 150 µg, mometasone furoate 320 µg inhalation powder cap, Breezhaler (DPI) | • 1 cap once daily inhalation at same time each day | • Maintenance therapy |
D. Long-acting muscarinic antagonists (LAMA)
| Drug | Dosage | Comments |
|---|---|---|
| Tiotropium 2.5 µg, solution for inhalation, Respimat® (Soft Mist Inhaler) | • 2 inhalations (5 µg) once/day, at same time of the day | • Maintenance therapy |
E. ICS/LABA/LAMA
| Drug | Dosage | Comments |
|---|---|---|
| Indacaterol acetate 150 µg, glycopyrronium bromide 50 µg, mometasone furoate 160 µg inhalation powder cap, Breezhaler® (DPI) | • 1 cap once daily inhalation at same time each day | • Maintenance therapy |
| Beclometasone dipropionate 100 µg, formoterol fumarate dihydrate 6 µg, glycopyrronium br 12.5 µg, pMDI | • 2 inhalations twice/day | • Maintenance therapy |
F. Leukotriene receptor antagonists (LTRA)
| Drug | Dosage | Comments |
|---|---|---|
| Montelukast 10 mg tablet | • 10 mg once/day (in the evening) | • Maintenance therapy |
G. Methylxanthine
| Drug | Dosage | Comments |
|---|---|---|
| Doxofylline 400 mg tablet | • 1 tablet twice or thrice/day | - |
H. Nebuliser
| Drug | Dosage | Comments |
|---|---|---|
| Ipratropium bromide 0.0125% nebulising solution (125 µg/ml) | Asthma exacerbation: • 500 µg; repeated doses can be administered (4 to 6 hourly). The time interval between the doses may be determined by the physician • It is advisable not to exceed the recommended daily dose • Daily doses exceeding 2 mg should only be given under medical supervision | Recommend to dilute the drug solution dose to a final volume of 4 – 5 ml in jet nebuliser unless the nebulizer is specifically designed for a small fill volume. |
| Ipratropium bromide 0.025% nebulising solution (250 µg/ml) | Asthma exacerbation: • 500 µg; repeated doses can be administered (4 to 6 hourly). The time interval between the doses may be determined by the physician • It is advisable not to exceed the recommended daily dose • Daily doses exceeding 2 mg should only be given under medical supervision | Recommend to dilute the drug solution dose to a final volume of 4 – 5 ml in jet nebuliser unless the nebulizer is specifically designed for a small fill volume. |
| Salbutamol 0.5 % nebulising solution | Asthma exacerbation: • 2.5 to 5 mg every 20 minutes for the first hour (3 doses), then 2.5 to 10 mg every 1 to 4 hours as needed, or 10 to 15 mg/hour by continuous nebulisation | Recommend to dilute the drug solution dose to a final volume of 4 – 5 ml in jet nebuliser unless the nebulizer is specifically designed for a small fill volume. |
| Ipratropium bromide 0.5 mg and salbutamol 2.5 mg/unit dose vial (UDV) | Asthma exacerbation: • 1 UDV every 4 to 6 hours | Recommend to dilute the drug solution dose to a final volume of 4 – 5 ml in jet nebuliser unless the nebulizer is specifically designed for a small fill volume. |
#Disclaimer: The information on common asthma medications in this section only serves as a general guide and is not all-inclusive. Doses may be different depending on formulation.
In the budesonide 160 µg / formoterol 4.5 µg Turbuhaler® row, "[...]" marks words missing from the CPG itself: the sentence breaks across two pages. The CPG gives no dose for the 80 µg indacaterol/glycopyrronium/mometasone capsule, so it isn't listed.
Asthma exacerbation
Recommendation 9
- Oxygen saturation of ≥94% should be maintained in all hypoxic asthma patients.
- In asthma exacerbation in emergency department, high flow nasal cannula should be considered over conventional oxygen therapy.
Recommendation 10
- In asthma exacerbation, inhaled β2-agonist is the first-line treatment.
- Oral short-acting β2-agonist (SABA) should not be used in asthma exacerbation.
The nebuliser doses of salbutamol and ipratropium bromide are in H. Nebuliser above.
Recommendation 11
- Systemic corticosteroids should be given in all patients with asthma exacerbation.
- These patients should continue their maintenance inhaled corticosteroids.
The CPG's steroid dose (Section 7.2): "The suggested daily dose of prednisolone ranges from 0.5 to 1 mg/kg of the ideal body weight with a maximum of 50 mg daily or 200 mg of intravenous hydrocortisone in divided doses. This dosage should be maintained for 5 to 7 days and can be stopped without gradual reduction."
On magnesium sulphate the CPG says: "In acute exacerbation of asthma not responding to initial treatments and have persistent hypoxaemia, a single 2 g infusion of the medication over 20 minutes reduces hospital admissions in patients with FEV1 <25 – 30% predicted at presentation."
Recommendation 12
- A single dose of 2 g intravenous magnesium sulphate infusion over 20 minutes should be considered in acute severe and life-threatening asthma.
On aminophylline the CPG says: "IV aminophylline has limited effectiveness apart from unfavourable AEs compared with standard therapy. Therefore, it should not be routinely used in asthma exacerbation. Consultation with a senior physician is advisable if its use is required."
Sources
- Malaysian Health Technology Assessment Section (MaHTAS), Ministry of Health Malaysia. Clinical Practice Guidelines: Management of Asthma in Adults, Second Edition. 2024. Recommendations 2, 5, 6, 9-12; Table 7; Section 7.2; Appendix 9. MaHTAS