• The Review Course in Family Medicine

Treating Very Mild and Mild Asthma

8 New Updates and 11 Key Recommendations from the 2021 Canadian Thoracic Society Guidelines

Asthma affects 3.8 million Canadians over the age of 1. Approximately 28-40% of this

population have mild or very mild asthma.

NEW Features and Updates for Management (see full article for details)

  • Well controlled asthma now defined as daytime symptoms ≤ 2 days per week and PRN SABA use ≤ 2 doses, down from 4 and 4, respectively

  • Risk of exacerbation added as a new parameter for selecting optimal treatment

  • Criteria for classifying exacerbations as mild or severe clarified

  • Indications for initiating daily ICS clarified

  • New treatment option available for ≥ 12 years with well-controlled asthma

  • Severity classifications updated

  • ICS dosing table revised

  • Asthma continuum discussed


11 KEY Recommendations for Treatment

  1. Recommended that control and exacerbation risk be assessed at each clinic visit

  2. PRN SABA alone OR daily ICS + PRN SABA OR PRN budesonide/formoterol recommended for ≥ 12 years if well-controlled asthma with low risk for exacerbation

  3. Daily ICS + PRN SABA OR PRN budesonide/formoterol recommended for those ≥ 12 with well-controlled asthma taking PRN SABA alone and if at high risk for exacerbations PRN budesonide/formoterol preferred if poor adherence.

  4. PRN SABA OR daily ICS + PRN SABA (patient preference) recommended for children <12 years with well controlled asthma at low risk for exacerbation

  5. Daily ICS + PRN SABA recommended for those aged <12 years with well controlled asthma and high risk of exacerbation

  6. Recommended that patients on PRN SABA with well-controlled asthma at lower risk for exacerbations continue PRN SABA alone instead of in conjunction with ICS at the time of administration

  7. Recommended that all patients with poorly controlled asthma on PRN SABA also take daily ICS instead of PRN SABA or PRN bud/form alone

  8. PRN budesonide/formoterol recommended instead of daily ICS + PRN SABA for patients ≥12 years with poor adherence to medication

  9. Recommended that patients on PRN SABA with poorly controlled asthma take daily ICS instead of taking ICS at the same time as SABA

  10. Daily ICS AND PRN SABA recommended for all patients with poorly controlled asthma OR those on daily low dose ICS with well-controlled asthma

  11. Short courses of very high-dose ICS with acute loss of asthma control NOT RECOMMENDED for patients on PRN SABA, irrespective of asthma control status


TAKE HOME MESSAGE

When considering mild and very mild asthma, PRN SABA +/- DAILY ICS recommended as first

line treatment, and BOTH together if at higher risk for exacerbations and if poorly controlled

disease.

New research has deemed PRN Budesonide/formoterol an effective additional or alternate

treatment option for those ≥12 years and is recommended as first line in cases of poor adherence.

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