TABLE 2.

Proposed evidence-based instructions for managing acute loss of asthma control in adults using an asthma action plan

Baseline controller medication (green zone)	Recommended changes during acute loss of asthma control (yellow zone)
ICS monotherapy	Increase the daily ICS dose by four- to five-fold for 7–14 days, provided the dose does not exceed the regulatory limit on total daily dose
What to do if a four- to five-fold increase exceeds the  daily dose limit
Fluticasone monotherapy at >500 µg total daily dose	Increase the total daily fluticasone dose to 2000 µg·day−1 for 7–14 days
Budesonide monotherapy at >600 µg total daily dose	Increase the total daily budesonide dose to 2400 µg·day−1 for 7–14 days
Ciclesonide monotherapy at >200 µg total daily dose	Increase total daily ciclesonide dose to 1600 µg·day−1 for 7–14 days#
Other medications	Option 1: increase the daily ICS dose by four- to five-fold for 7–14 days, temporarily exceeding the regulatory limit on total daily dose¶
	Option 2: prednisone 30–50 mg daily (or equivalent OCS regimen) for 5–7 days+
Fixed dose ICS/LABA combination therapy	Increase the daily ICS dose by four- to five-fold for 7–14 days, provided the dose does not exceed the regulatory limit on total daily dose of ICS (add ICS alone unless increase of ICS/LABA possible without surpassing regulatory limit on total daily dose of LABA)
What to do if a four- to five-fold increase exceeds the  daily dose limit
Fluticasone/salmeterol at >500 µg fluticasone total daily dose	Increase the total daily fluticasone dose to 2000 µg·day−1 for 7–14 days (by adding fluticasone)
Budesonide/formoterol at >600 µg budesonide total daily dose	Increase the total daily budesonide dose to 2400 µg·day−1 for 7–14 days (by adding budesonide)
Other medications	Option 1: increase the daily ICS dose by four- to five-fold for 7–14 days, temporarily exceeding the regulatory limit on total daily dose (by adding an ICS to the ICS/LABA therapy)¶,§
	Option 2: prednisone 30–50 mg daily (or equivalent OCS regimen) for 5–7 days+
ICS/formoterol combination therapy using MART approach	Continue MART therapy as prescribed
Special clinical scenarios
Patients with a history of sudden and severe exacerbations   and/or presenting with PEF or FEV1 ≤60% of personal   best/predicted (severe exacerbation)	Prednisone 30–50 mg daily (or equivalent OCS regimen) for 5–7 days+
Patients who fail to improve clinically within 2–3 days of   increase in controller medication, and/or have a rapid   clinical deterioration, and/or have a PEF or FEV1 that   falls to ≤60% of their personal best value	Prednisone 30–50 mg daily (or equivalent OCS regimen) for 5–7 days+

^#: this dose exceeds regulatory limits (across jurisdictions) for routine daily use but has been shown to be safe and effective for treatment of acute loss of asthma control, in a clinical trial. ^¶: total daily dose limits are intended for chronic daily use and a short-term dose increase beyond these limits is unlikely to carry any significant safety risks. However, formal safety testing data are not available and the decision to pursue this approach should be based on patient and clinician comfort. ⁺: in patients with adequate experience self-managing their asthma, consider providing a standing prescription for oral corticosteroid (OCS) for these situations, with instructions to contact the primary healthcare provider after initiating OCS. For others, advise contacting their physicians to obtain an OCS prescription if they meet the criteria outlined in the asthma action plan. Ensure that all patients are appropriately counselled about the risks of short-term OCS use. ^§: fluticasone furoate/vilanterol inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) therapy can simply be quadrupled. Although the resulting vilanterol dose (100 µg) daily would exceed regulatory limits, this has been shown to be safe for short courses of therapy (see text for references). MART: ICS/formoterol as maintenance and reliever therapy; PEF: peak expiratory flow; FEV₁: forced expiratory volume in 1 s.