Partnership HealthPlan of California
Asthma Clinical Decision Flow Chart
Asthma
Updated: 08/13/2013
Author: Dr. Moore/OM
*Note: Not-well controlled
asthma should be
documented with Asthma
Symptom Scale and/or Peak
Flow Diary
NIH defines “not-well
controlled” as sx more than
twice a week or peak
variability more than 20%
Intermittent Asthma (sx<3x weekly),
Reliever medication only
Disease
Intermittent or
Persistent
Persistent Asthma Controller Medication
ImunnoCAP
Albuterol Formulations:
Formulary:
MDI-Ventolin HFA*
Tabs
Oral liquid
Neb-#225/month
*Note-Proair HFA,
Proventil HFA-NF
Key:
LABA-Long acting beta agonist
ICS-Inhaled corticosteriod
MDI-Meter dose Inhaler
Neb-Nebulizer
NF-Non formulary
T/F-Tried and Failed
SE-Side Effects
Green Shade-<$50
Yellow shade-$51-$200
Red Shape->$201
First Line Controller medications (May use one or more together)
Albuterol MDI (with
spacer)
Thrush or
Dysphagia
Results
Address
Environmental
Measures
neg
Acute Med
Albuterol MDI (with
spacer)
Pos
Adequate relief
for exacerbations
ICS-MDI
Formulary
Montelukast
(Singular)
Formulary: tabs/
chewables
Side effects
Acute Medication
Defined
Formulary ICS:
Ciclesonide (Alvesco)
Fluticasone(Flovent HFA)
Beclomethasone(Qvar)
Mometasone(Asmanex)
Budesonide(Pulmicort)MDI
Limited to 1 unit/mon.
Zafirlukast
(Accolate)
STEP
ICS Prodrug MDI:
Ciclesonide
(Alvesco)
Inadequate
Relief
Side effect:
Intolerable tachycardia
results
Levalbuterol
(Xopenex) MDI, NF
Insufficient
Control?
(Objectively
Determined)*
Controlled
Sx <3x/week
Yes: Add
Inadequate acute relief
Objectively determined*
LABA(NF):
Salmeterol(Serevent)
Formoterol(Foradil)
Limited to 1 unit/mon.
Options for Moderate Acute symptoms
Asthma under
control
5 day course of oral
corticosteroid
No
Albuterol Nebulized
Unacceptable
Tachycardia
LABA
NF
Asthma Controlled
No
Failure of first
line Medication?
(Objectively
Determined)*
Yes, if PO med helpful:
Add
Yes, Substitute
Theophylline
(Theodur tabs)
Formualry
ICS/LABA
Combination
NF
Use ½ vial albuterol
nebulized
Second Line Medications
Still intolerable tachycardia
Consider specialist referral if
needing prednisone bursts more
than twice a year
Controlled
Yes
Asthma Specialist
Confirms Diagnosis,
Optimizes use of
First and Second line
medications
Levalbuterol
(Xopenex) MDI, NF
With spacer
Sufficient Relief?
Referral to Asthma
Specialist for
consultation
No
Formulary Oral
Corticosteriods:
Prednisone-tabs ,liquids
Prednisolone-liquid
methylprednisolone
Third Line Medication Options
Referral to Allergy/
Asthma specialist
Consider Epi Pen
Consider
Levalbuterol
Nebulized, if unable
to use Levalbuterol
MDI-NF
F/U
Consider Referral To
Emergency Room
Allergen specific
serious reaction
Budesonide
Nebulized (rarely
better than well
administered ICSMDI)-NF
Unable to control or
Serious side effects of
Oral Corticosteroids
Yes
No
ICS/LABA combination:
Fluticasone/Salmeterol
(Advair)-NF
Budesonide/Formoterol
(Symbicort)-STEP,
Preferred
Mometasone/Formoterol
(Dulera)- STEP, Preferred
Limited to 1 unit/mon.
Able to achieve
control with
second-line
Medications?
No
Oral corticosteroids
(potentially serious
side effects with
long-term use)
*Spirometry done
prior to proceeding
to second line
agents
Controlled?
Yes
Asthma Controlled
By 6 months later:
Step down therapy (LABA,
Third or Fourth line
medication) or justify why
not
Fourth Line Options
Significantly Reduced exacerbations
Allergen
desensitization
Ziluton
(Zyflo)
Cost-$1900.
NF
Effect of Shortterm Trial
Little or no effect
Stop Fourth Line
modality;
Consider Xolair trial
NF