Asthma Step Up Therapy - Everything You Need To Know

According to the American College of Allergy, Asthma, and Immunology¹ (ACAAI), the prevalence of asthma in the United States is about 9.4% among children and 7.7% among adults. Women (9.2%) are more likely to be diagnosed than men (7%). 

Although the percentage of the population with the condition can be seen as reasonably low compared to other diseases, the health risks associated with asthma—e.g., pneumonia, narrowing and thickening of bronchial tubes, severe chest pain, and respiratory symptoms or failure—can be severe. 

The same ACAAI report noted 1.3 million emergency room visits and 439,000 hospitalizations yearly due to this condition. 

Patients with asthma experience chronic inflammation of their lungs that can damage lung function, make breathing difficult, and cause wheezing, coughing, and tightness in the chest. Proper management is critical for patients with asthma because uncontrolled asthma² has more associated risks, particularly severe disease or death.

This is where step-up asthma therapy comes in as a solution for managing asthma. 

What is asthma step-up therapy?

Asthma step-up therapy is the gradual process of treating asthma symptoms using an approach to asthma management called stepwise. This strategy is used to gradually “step-up” medication use in patients struggling to control their asthma.

It can be short-term (Step-Up Short-Term or SST) for patients with a more temporary loss of control or long-term (Step-Up Long-Term or SLT) in more severe asthma cases with ongoing and persistent asthma attacks. 

In the short term, your doctor may take you off the therapy after 3–10 days of controlled asthma symptoms following your step-up treatment. If the severity of your asthma varies daily, you may follow a step-up therapy called step-up intermittent (SUI) that is more personalized to you and your condition.  

The stepwise approach comes in six steps that vary by age:

Step 1

For all ages, the first stage of medication for patients with mild asthma consists of taking a short-acting beta-agonist. Also known as bronchodilators, it increases airflow in 2–6 hours. It relaxes the muscles lining the airways that carry air to your lungs. 

This is typically a prescription such as an inhaler with albuterol prn (which means “as needed”) as a preventative or as-needed basis. You will “step up” to step 2 and higher only after taking your medication twice a week.

Step 2

For all ages, step 2 consists of taking a low-dose inhaled steroid. Ages four and under, however, require a referral. 

Step 3

For adults and children 12 and older with asthma, step 3 will require a combination of low-dose inhaled steroids and either a long-acting beta-agonist (used for increasing airflow in 12 or more hours by relaxing the muscles lining the airways that carry air to your lungs) or a medium-dose inhaled steroid. 

Those between five and 11 years old may also take this combination of medications in step 3 or take a low-dose inhaled steroid and leukotriene blocker instead. Patients four years old and under may take a medium-dose inhaled steroid as long as their doctor has referred them. 

Step 4

In step 4, patients five and older may take a medium-dose inhaled steroid and long-acting beta-agonist. 

Those four or younger typically take a combination of a medium-dose inhaled steroid and either a long-acting beta-agonist or a leukotriene blocker. Leukotriene blocker is a group of medications that block or prevent your body from producing leukotrienes, which reduces the effect of allergy symptoms. 

Before stepping up to this level, a consult with an asthma specialist is required.

Step 5

In step 5, those between five and 11 can take a high-dose inhaled steroid and a long-acting beta-agonist. These medications are recommended for patients 12 and older. They should also consider omalizumab (an injection that reduces allergy-induced asthma attacks and chronic hives) if allergies trigger their asthma. 

A high-dose inhaled steroid with either a long-acting beta-agonist or leukotriene blocker are recommended for patients four years and below.

Before stepping up to this level, a consult with an asthma specialist is required.

Step 6

In step 6, patients between five and 11 typically continue taking a high-dose inhaled steroid with a long-acting beta-agonist. While patients 12 and older are recommended to take the same treatment in this step, they are also advised to take an oral steroid and consider taking omalizumab if allergies trigger their condition. 

Those four and under in step 6 are recommended to take a high-dose inhaled steroid with either a long-acting beta-agonist or a leukotriene blocker and an oral steroid.  

Before stepping up to this level, a consult with an asthma specialist is required.

Note that these are the preferred treatments for each step. An alternative treatment for some steps may be implemented if your medical professional sees fit. 

Your healthcare provider will likely reassess you between two and six weeks after starting you on the step-up therapy. If your asthma is well-controlled again, you may begin the “step-down” stages of the treatment to get you off the medications. 

Three months following your step-down, your healthcare provider will assess your control again to ensure your asthma is properly managed. 

How can asthma step-up therapy help you control your asthma symptoms?

Controlling asthma symptoms is a significant challenge. However, it is the most important step to living a good quality of life with asthma. 

The Asthma and Allergy Foundation of America³ reports that although asthma is the most common and costly disease in the US that cannot be cured, “appropriate treatment prevents asthma attacks and can help you have a better quality of life.” 

Uncontrolled asthma leads to nearly $3 billion in losses from missed work and school days, up to $29 billion in asthma-related mortality, and as much as $50.3 billion in medical costs. 

Step-up therapy helps you control asthma symptoms and reduce attacks by considering your individual needs for asthma medication treatment and implementing a gradual step-up method that works best for you. 

This, in turn, will allow you to control symptoms much easier during times where you’re highly vulnerable via SST, after long periods of difficulty managing symptoms with SLT, and more unique cases with SUI. 

According to research,⁴ the individualized treatment goals of step-up and step-down approaches “maximize treatment benefits and minimize potential adverse” among children and adolescents. Another study supports the treatment⁵ of youths 12 and older and adults.  

When should you consider starting asthma step-up therapy?

You should consider starting asthma step-up therapy if you cannot control your attacks and symptoms. However, the stepwise approach says that you should start “stepping up” if you experience attacks and symptoms two days per week or more in the first stage of step-up therapy. 

The preferred option for the first step of the stepwise approach with patients with mild asthma and without serious risk factors is low-dose inhaled corticosteroids (ICS).⁶ These are used as needed by both adults and children. If your as-needed basis becomes more common, consult your doctor as soon as possible. 

Therefore, if you have two or more signs of uncontrolled asthma in a week, you should consider step-up asthma therapy.

However, you may want to discuss the possibility of step-up therapy with your doctor if you have it once a week and occasionally twice a week. It may be a sign of severe exacerbations (worsening of your condition), signaling that your asthma is not under proper control. 

How to start asthma step-up therapy

Not every patient with asthma will need step-up therapy to control their condition. The American Lung Association⁷ says that only about 5–10% of the more than 25 million US people with asthma have severe asthma. 

For those with severe or uncontrolled asthma, the following process may be followed to start step-up therapy. 

Obtain a diagnosis

First and foremost, you must be diagnosed with asthma. According to research,⁸ it is no longer acceptable to base an asthma diagnosis—on adults, adolescents, or children—on just history, a physical examination, and an evaluation of the patient’s response to a trial therapy. 

Instead, diagnosing asthma is made through a combination of two or more of the following, with tests varying by age:

• Personal and medical history 

• Physical exam

• Lung function tests such as spirometry, peak airflow, feNO tests (exhaled nitric oxide), and provocation tests

It’s also common for your doctor to run an allergy test to see if that’s the cause of your asthma and other tests like x-rays and acid reflux tests to determine if your symptoms result from something else. 

Note that diagnosing asthma in children under five is not the same. Instead of a breathing test, your child’s pediatrician often prescribes a bronchodilator.

If it works, then your child likely has asthma. Fortunately, about 50%⁹ of children with asthma “outgrow” the condition in adolescence, although it can reappear in adulthood. 

Have the severity of your asthma assessed 

The severity of your asthma will determine whether or not you need to start or continue the step-up therapy program.

To test for asthma severity levels,¹⁰ your doctor will likely conduct spirometry to test how much air you’re inhaling, how much is exhaled (and how quickly), and how fast your lungs can be emptied of air. 

They may also have you use a handheld device called a Peak Flow Meter that takes daily measurements of your breathing. 

Start taking medication

After your diagnosis of asthma and evaluation of severity, your doctor will initiate a low dose of medication and gradually increase the dosage as needed. The Global Initiative for Asthma¹¹ (GINA) now has two tracks for introducing medications for symptom relief. 

Track 1

In Track 1, GINA identifies low-dose ICS (inhaled corticosteroids)-formoterol (type of asthma medication classified as long-acting beta-agonists) as the preferred medication choice. Their reports found that using ICS-formoterol over SABA (short-acting β-agonist drugs) reduces the risk of severe exacerbations. 

Track 2

In Track 2, SABA is used as the reliever and offered as an alternative approach. The GINA report says to use Track 2 only if Track 1 is not possible or if it is preferred by a patient who doesn’t currently experience severe asthma exacerbations. Note that there are more risks to following a SABA-only treatment. 

Following the stepwise approach mentioned earlier, the treatment in either track can be stepped up or down, depending on your needs and preferences. 

What are the potential side effects of asthma step-up therapy?

Potential side effects of asthma step-up therapy vary depending on the medication you are taking, which all have the potential for some side effects and, in rarer cases, serious side effects. 

For instance, Track 1’s ICS and Track 2’s SABA side effects are as follows.

Common side effects

For ICS, the common side effects are: 

• Croaky or hoarse voice

• Sore throat

• Coughing

• Nosebleeds

• Oral thrush (a fungal infection in the mouth)

• If taken at high doses for a long time, you may also experience mood changes, increased appetite, and difficulty sleeping 

For SABA, common side effects may include: 

• Muscle cramps

• Nervousness

• Trembling in the hands

• Headaches

• Heart palpitations

Serious side effects

In more severe cases, patients taking ICS at high doses for a long time may experience systemic side effects such as:

• Impaired growth in children

• Decreased bone mineral density

• Skin thinning and bruising

• Cataracts

Patients taking SABA, on the other hand, may experience more severe side effects such as:

• A sudden tightening of your airway

• Heart attack

• Hypokalemia (severely low levels of potassium in the blood)

How to know if asthma step-up therapy is working for you

Aside from the regular assessments with your primary care doctor, who will evaluate if the asthma step-up therapy is working for you, you may also see some signs of improvement yourself. 

For instance, if the therapy is working, you should notice:

• Having fewer asthma attacks

• Having improvements in asthma control

• Your symptoms remaining under control even after you begin to “step down”

Discuss your experience with the therapy treatment in full with your healthcare provider to ensure they are up to date on how it is working for you and whether or not it’s time to step down or make any adjustments. 

If you do not notice improvements in asthma control, also tell your doctor. 

When to visit your doctor

You should consult your doctor on potential solutions if you have asthma and experience severe or worsening symptoms. 

Being open and honest about your experiences will allow your doctor to treat you to the best of their ability and make changes to improve your treatment plan when needed. This may or may not be step-up therapy. However, it is worth considering as an option. 

Likewise, if you’re not noticing any improvement or are experiencing severe side effects that are declining your quality of life, you should consult your doctor. The main point of step-up therapy is to get your asthma symptoms under control, so if it isn’t working for you, changes should be made to suit your treatment needs better. 

You will likely already be reviewed every one to six months for asthma control. However, your doctor should hear about any exacerbations, particularly severe ones, before scheduled assessments. 

The lowdown

Although asthma can become severe—even in predominantly mild cases of the condition—following a treatment that successfully manages your attacks and symptoms will allow you to live a high-quality life and reduce the risks associated with this airway disease. Asthma step-up therapy is one of those options if you and your healthcare provider struggle to control your condition. 

Although it is linked to several studies that found it to be an effective form of treatment as it allows your doctor to personalize your treatment plan to fit your specific case, step-up therapy also has side effects. 

These side effects are connected to the medications you take during therapy, particularly as you increase the dosage. For ICS, this includes symptoms such as nosebleeds, coughing, sore throat, and a hoarse voice. On the other hand, SABA can cause you to experience side effects such as muscle cramps, trembling, headaches, and even heart palpitations. 

Since side effects and treatment outcomes vary from patient to patient, you must always keep your doctor in the loop. Never try anything new without consulting them first, and always inform them of side effects, your preferences, and any improvements or worsening effects during the treatment. 

This will allow them to make any necessary adjustments to your treatment plan to increase your quality of life and reduce attacks and symptoms.