Follow Stepwise Approach to Manage Allergic Asthma

Pharmacy TimesMay 2023
Volume 89
Issue 5

This treatment approach helps reduce symptoms and future exacerbations triggered by dust mites, pet dander, pollen.

Stepwise treatment may be the best approach to managing allergic asthma, which occurs when the body overreacts to a benign substance, mistaking it for an intrusive invader. Antibodies attach to the allergen and begin the immune response, which releases chemicals such as eosinophils, epithelial cells, macrophages, mast cells, neutrophils, and T lymphocytes. These all contribute to inflammation, which leads to symptoms of asthma, such as chest tightness, coughing, shortness of breath, and wheezing.1

Asthma, woman: © RFBSIP -

Asthma, woman: © RFBSIP -


Asthma is an obstructive airway disorder that limits expiratory airflow and results from bronchospasm, increased airway secretions, and inflammation; its main risk factor is a history of atopic disease.2 Individuals with eczema or hay fever have a much higher risk of developing allergy-induced asthma.3

Environmental factors include airborne pollutants, emotional stress, exercise, gastroesophageal reflux disease, hyperventilation, and hormonal changes. These may affect asthma severity and act as a trigger, leading to asthma exacerbation.3

Both indoor and outdoor allergens and pollutants must be considered. These can include biologic allergens, such as animal dander, cockroaches, dust mites, and mold. They also include high ozone level, irritant chemicals and fumes, and traffic pollution. In addition, smoking during and after pregnancy is related to the risk of developing asthma.3


According to the CDC, 25.7 million Americans, or approximately 1 in 13, have asthma.4 Other key statistics include4:

  • Asthma affects males at a rate of 6.1% and females at a rate of 9.5%.
  • Asthma is the most common noncommunicable disease in children.
  • In 2010, 1.8 million individuals visited an emergency department (ED) for asthma-related care, and 439,000 were hospitalized because of asthma.
  • Most asthma-related deaths occur in older adults.
  • The prevalence of asthma in White populations is 8.1%, 10.3% in Black populations, and 6.6% in Hispanic populations.


The pathophysiology of asthma is characterized by variable airflow constriction and hyperresponsiveness. This causes a contractile response of the airway.

The inflammation of the airway is thought to be from mast cell activation mediated by a variety of cells and cytokines similar to the pathogenesis of allergic rhinitis.5

Eosinophils are the most specific cells accumulating in asthma and allergic inflammation and correlates with asthma severity. Variable narrowing of the airway causes variable reductions of airflow, which is the hallmark of asthma.5

Bronchoconstriction may be caused by contractile agonists released during the inflammatory response. There are a variety of environmental, genetic, and infectious factors that modulate whether susceptible individuals progress to overt asthma.5


The goal of allergic asthma management is to reduce impairment and the risk of future asthma exacerbations. Achieving and maintaining control involves a multifaceted approach that includes addressing environmental factors that worsen symptoms, appropriate medication, and patient education on self-management and monitoring skills to adjust therapy accordingly.

Allergen and environmental control are very important in asthmatics. Keeping a home free of cockroaches, dust mites, and excessive humidity is key in controlling allergic asthma. Removing pets, especially cats, can also improve the environment’s allergen level. Tobacco exposure should be avoided as well; it has been shown to decrease lung function and increase medication requirements.

In addition to avoiding allergens, individuals can manage allergies with allergen immunotherapy (allergy shots, sublingual tablets), anticholinergic agents (ipratropium bromide), antihistamines (cetirizine), mast cell stabilizers (cromolyn sodium), and nasal corticosteroid sprays (fluticasone). Ideally, these will prevent progression to asthma.

Asthma medications are classified according to their roles in the overall management of asthma. Some medications are used in the acute setting, whereas others are used as maintenance therapy. All patients should have a fast-acting bronchodilator rescue inhaler for acute exacerbations.

The National Asthma Education and Prevention Program recommends a stepwise approach to the management of asthma based on age and asthma severity. Where a patient should begin is determined by how intense the asthma is initially.6

If a drug is not enough to control a patient’s asthma in 2 to 6 weeks, the treatment goes up a step. This may mean adding another drug or increasing the dose. If a patient’s asthma is well controlled for at least 3 months, the treatment may go down a step.7

In general, the types of medications prescribed for asthma severity vary by age but include7:

  • Asthma biologics•Inhaled corticosteroids
  • Immunotherapy
  • Leukotriene receptor antagonists
  • Long-acting beta -agonists
  • Long-acting muscarinic antagonists
  • Short-acting beta -agonists

For more information on all the steps, check out the Guidelines for the Diagnosis and Management of Asthma.7


Complications from allergic asthma exist, but long-term complications are uncommon. Some common complications include absence from school or work, ED visits and hospitalizations, interference with normal activities, and sleep disturbance. Long-term complications are usually caused by chronic inflammation, which can lead to damaged airways. Death from asthma is rare, but the risk increases in patients with underlying lung disease, as well as smokers.

Patient Education

Educate patients with asthma about the use of medications. They should understand how to take medications and know the differences between maintenance and rescue medications. Pharmacists should encourage patients to use asthma action plans so they understand that when their symptoms are severe they must contact their physician or go to an ED.

Of utmost importance in the prevention and management of asthma-associated outcomes is the communication among the members of an interprofessional team of clinicians, pharmacists, and specialized nurses.

Communication between clinicians and pharmacists about medication nonadherence helps identify patients at higher risk for asthma exacerbations.

The same is true for patients who use their rescue inhalers frequently.


1. What is allergic asthma? Allergy & Asthma Network. Accessed April 8, 2023.

2. Allergic asthma defined. American Academy of Allergy, Asthma, & Immunology. Accessed April 8, 2023.,-Asthma-Immunology-Glossary/Allergic-Asthma-Defined

3. What are asthma triggers? Asthma and Allergy Foundation of America. Updated October 2019. Accessed April 9, 2023.

4. Most recent national asthma data. CDC. Updated December 13, 2022. Accessed April 9, 2023.

5. Sinyor B, Concepcion Perez L. Pathophysiology of asthma. StatPearls; 2023. Accessed April 9, 2023.

6. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2022. Accessed April 9, 2023.

7. Asthma management guidelines: focused updates 2020. National Heart, Lung, and Blood Institute. Updated February 4, 2021. Accessed April 9, 2023.

About the Author

Kathleen Kenny, PharmD, RPh, is a clinical medical writer for Healthline Media in Colorado Springs, Colorado.

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