Ciclesonide | place in therapy review Table 2 | Pharmacologic management of asthma: stepped approach (adapted from Anon. 2005b) Category of asthma Adults and children >5 years Intermittent Mild persistent Moderate persistent Severe persistent Infants and young children <5 years Mild intermittentb Mild persistent Moderate persistent Severe persistent 236 Characteristics • Symptoms <once/week • Brief exacerbations • Nocturnal symptoms ≤2 nights/month • FEV1 or PEF ≥80% predicted • PEF or FEV1 variability <20% • Symptoms >once/week, but <once/day • Exacerbations may affect activity and sleep • Nocturnal symptoms >2 nights/month • FEV1 or PEF ≥80% predicted • PEF or FEV1 variability 20–30% • Daily symptoms • Exacerbations may affect activity and sleep • Nocturnal symptoms >once/week • Daily use of short-acting inhaled beta2 agonist • FEV1 or PEF 60–80% predicted • PEF or FEV1 variability >30% • Continuous symptoms • Frequent exacerbations • Frequent nocturnal symptoms • Limitation of physical activities • FEV1 or PEF 60% predicted • PEF or FEV1 variability >30% • Symptoms <once/week • Brief exacerbations • Nocturnal symptoms <2 nights/month • FEV1 or PEF ≥80% predicted • PEF or FEV1 variability <20% • Symptoms >once/week, but <once/day • Exacerbations may affect activity • Nocturnal symptoms >2 nights/month • FEV1 or PEF ≥80% predicted • PEF or FEV1 variability 20–30% • Daily symptoms • Exacerbations affect activity • Nocturnal symptoms >once/week • FEV1 or PEF 60–80% predicted • PEF or FEV1 variability >30% • Continuous symptoms • Frequent nocturnal symptoms • Limitation of physical activity • FEV1 or PEF ≤60% predicted • PEF or FEV1 variability >30% Daily medicationa • None • Low-dose inhaled corticosteroid • Alternative: cromolyn, leukotriene modifier, nedocromil, or sustained-release theophylline • Low to medium-dose inhaled corticosteroid and long-acting inhaled beta2 agonist • Alternative: – Increase inhaled corticosteroid within medium dose range or – Low to medium-dose inhaled corticosteroid and either leukotriene modifier or theophylline • High-dose inhaled corticosteroid and long-acting inhaled beta2 agonist • If needed: oral corticosteroid, sustained-release theophylline, leukotriene modifier, antiimmunoglobulin E antibody (adults and children ≥2 years) • None • Low-dose inhaled corticosteroid • Alternative: cromolyn, leukotriene modifier, nedocromil, or sustained-release theophylline • Low-dose inhaled corticosteroid and long-acting inhaled beta2 agonist (if needed medium dose can be used) or • Medium-dose inhaled corticosteroid • Alternative: low-dose inhaled corticosteroid (if needed medium dose can be used) and leukotriene modifier or theophylline • High-dose inhaled corticosteroid and long-acting inhaled beta2 agonist • If needed: oral corticosteroid © 2006 Core Medical Publishing Limited aA short-acting inhaled beta2 agonist should be used as needed to relieve acute symptoms; use should be limited to no more than 3–4 times/day. bChildren with intermittent asthma but severe exacerbations should be managed as having moderate persistent asthma. FEV1, forced expiratory volume in 1 s; PEF, peak expiratory flow.