Overview

Part 1: Personalized Asthma Management — Assess, Adjust, Review

🔵 ASSESS

• Symptoms — frequency, nocturnal symptoms, activity limitation
• Exacerbations — how many, how severe, need for oral steroids or ER visits
• Side effects of current medications
• Comorbidities — allergic rhinitis, eczema, obesity, etc.
• Lung function — spirometry or peak flow where available
• Child and parent/caregiver satisfaction with current management

• Confirmation of diagnosis if necessary
• Symptom control and modifiable risk factors
• Comorbidities
• Inhaler technique and adherence
• Child and parent/caregiver preferences and goals

🟠 ADJUST

• Modifiable risk factors and comorbidities (e.g., smoking exposure, obesity, allergen sensitization)
• Non-pharmacological strategies — trigger avoidance, allergen immunotherapy consideration, physical activity promotion
• Asthma medications including ICS — stepping up or down the pharmacological ladder
• Education and skills training, action plan — written asthma action plan for child and caregivers

🔵 REVIEW

Part 2: Asthma Medication Options — 5-Step Ladder

STEP 1

• Low-dose ICS taken whenever SABA is taken* (i.e., as-needed ICS-SABA)

STEP 2

• Daily low-dose inhaled corticosteroid (ICS) — see dose table for children

• Daily leukotriene receptor antagonist (LTRA†) (e.g., montelukast) — useful when ICS is not tolerated or in allergic rhinitis comorbidity, but carries a† advisory regarding neuropsychiatric adverse effects
• Low-dose ICS taken whenever SABA is taken* — the as-needed ICS-SABA strategy is also acceptable here

STEP 3

• Low-dose ICS + LABA — combining ICS with a long-acting beta₂-agonist for better symptom control
• Medium-dose ICS — escalating the ICS dose alone
• Very low-dose ICS-formoterol MART* — Maintenance And Reliever Therapy using a single inhaler (ICS-formoterol) for both daily maintenance and as-needed relief. This reduces exacerbation risk even at low total ICS doses.

• Low-dose ICS + LTRA†

MART (*) refers to ICS-formoterol used as both maintenance and reliever in the same inhaler. The formoterol component has rapid onset, making it suitable as a reliever. The MART strategy has strong evidence for reducing severe exacerbations.

STEP 4

• Medium-dose ICS-LABA — escalating the ICS dose combined with LABA
• Low-dose ICS-formoterol MART* — continued at this step
• Or refer for expert advice

• Add tiotropium (LAMA — long-acting muscarinic antagonist) — a bronchodilator add-on
• Add LTRA†

STEP 5

• Refer for phenotypic assessment — identifying the child's asthma endotype (e.g., eosinophilic, allergic, type-2 high) to guide targeted biologic therapy

• Higher-dose ICS-LABA
• Anti-IgE (omalizumab) — for allergic asthma with elevated IgE
• Anti-IL-4Rα (dupilumab) — for type-2 inflammation
• Anti-IL-5 (mepolizumab, benralizumab) — for eosinophilic asthma

• Low-dose oral corticosteroids (OCS) — only as a last resort due to significant systemic side effects (growth suppression, adrenal suppression, metabolic effects). Side effects must be carefully considered and discussed with the family.

Reliever Therapy (Bottom Row)

• As-needed SABA (short-acting beta₂-agonist, e.g., salbutamol) — used at all steps
• ICS-formoterol reliever* — used in Steps 3 and 4 when on MART strategy, replacing SABA as the reliever

GINA 2025 strongly discourages SABA-only treatment (without a controller) even for mild asthma, as this increases exacerbation risk.

Key Abbreviations (from footnote)

Clinical Takeaways

1. No child with persistent asthma should rely on SABA alone — every child needs a controller.
2. Step up if symptoms are uncontrolled after 2–3 months; step down if well-controlled for ≥3 months.
3. MART is a powerful strategy from Step 3 onwards — one inhaler for both maintenance and relief simplifies regimens and reduces exacerbations.
4. Biologics are reserved for Step 5 severe, treatment-refractory asthma with a confirmed phenotype.
5. The Assess–Adjust–Review cycle should happen at every clinical encounter, not just at annual reviews.