<p>Rescue inhalers may relieve symptoms quickly, but daily maintenance therapy treats the underlying airway inflammation that drives asthma. Step-up and step-down approaches aligned with Global Initiative for Asthma (GINA) recommendations should be used when managing asthma with rescue and maintenance medications, and newer reliever strategies, such as pairing an ICS with bronchodilation, may improve outcomes compared with short-acting bronchodilator use alone.</p>

Asthma is a chronic condition that leads to airway inflammation and obstruction, and patients with asthma may also have intermittent symptoms. Rescue medications that patients use acutely to relieve their symptoms include short-acting bronchodilators that have an instantaneous effect, relaxing the smooth muscle and opening the airway. They treat acute exacerbation and should not be used daily.

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Other asthma medicines treat some of the underlying problems associated with the disease (ie, mainly airway inflammation and obstruction). These maintenance treatments are taken every day and not when needed, except in patients with very mild asthma. They are used to maintain disease control, prevent exacerbation, and improve symptoms, and they include long-acting bronchodilators and ICS agents.

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Distinguishing between when to use a rescue reliever medication and when to use a maintenance medication for control is very important for clinicians when we prescribe asthma medicines. However, more importantly, patients should understand that these medications work through different mechanisms. In real life, unfortunately, many patients with asthma are reliant on their rescue medication and are often poorly compliant or adherent with their maintenance medication.

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When managing asthma with rescue and maintenance medications, we should use both step-up and step-down approaches. Depending on how controlled and severe the asthma is, we build up the treatment plan based on recommendations from GINA. Step 1, for example, includes patients with mild asthma who have intermittent symptoms for whom rescue inhalers such as a SABA may be enough. However, as we go up in the steps, with higher steps reflecting more severe and less controlled disease, we go up in the algorithm. We start by using maintenance controllers on a regular basis, maybe ICS therapy initially, but sometimes we add LABAs and then increase the dose of the ICS as the asthma control or disease severity worsens. We basically step up the approach to the extent of that for people in steps 4 and 5 with severe or moderately severe disease, in whom multiple controllers have to be used at the same time. Fortunately, now we have combination treatments, where all these drugs may be in 1 inhaler. For patients with more severe disease, like step 5, we may have to contemplate using an injectable biologic.

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One cannot forget that a step-down strategy is important as well. If we step up and control the asthma, we should assess asthma control at each visit, as recommended by GINA, and try to taper some of these medications, particularly the steroid dose, because of dose-dependent side effects.

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Our thoughts about the use of ICS agents alone as maintenance have changed only recently. Recent data have shown that using a SABA alone as rescue therapy may be associated with worse outcomes compared with using an ICS and a LABA combination such as budesonide-formoterol. When this combination is used as rescue therapy alone in patients with mild asthma, we call it an “anti-inflammatory reliever.” Further, “maintenance and reliever therapy” (also known as MART) is the strategy of using an ICS and a LABA for both maintenance and rescue in patients with more severe asthma. This information is included in the latest GINA treatment recommendations. However, in the United States, the US Food and Drug Administration (FDA) has not cleared budesonide-formoterol as rescue therapy; it is only currently FDA approved as maintenance therapy. We do, however, have the SABA and ICS combination therapy of albuterol and budesonide approved in the United States. According to the GINA step-up approach, instead of using albuterol alone, it is recommended to use the combination. This strategy has been shown to be superior to albuterol alone.