With regard to your second question about directly going to combination therapy. I would suggest against doing that. There is a reason all international guidelines advice against doing that and that is overtreatment. Each type of medication you give can result in side-effects. Especially in primary care most of your asthmatics will do just fine with monotherapy ICS, so why risk side-effects? Additionally, you should actually try to step down your monotherapy as well, if patients are controlled for a prolonged period of time. Don't underestimate side-effects and when a patient doesn't need a medication, do not give it (primum non nocere).

Also, I don't think combination therapy is easier to use, the inhalation devices are much the same as mono-therapy. Only if you decide to use both types, it is easier to have it in one device.

thank you for your reply

Well despite the Guidelines which we often forget are just that and do not equally apply to all patients--I prefer an individualized approach.

I am assuming This is a child old enough to do pulmonary function tests--if so the results can guide you,  The paient is having syptoms--yes? If the Pulmonary Function Test is fairly normal(=/> 80%) then this tell me that they do not need a LABA but more ICS .  One reason they may need more they are not taking correctly what they have been given---not inhaling correctly --and/or using less frequent doses than recommended.  Before increasing the dose check what they are doing---and remember patients do not always tell you the entire truth.

Even before adding a LABA, if the Mid Flow Rates (FEF 25-75%) are low consider the small airways may not be getting the ICS because some ICS have too large of a particle size to reach the small airway--So switch brands or delivery system. ( Dry Power Inhalers have the largest particle size so switching to a MDI/HFA system may be enough.

If one needs to increase the dose of ICS --I would never go above the recommended dose without careful adverse effect monitoring (Growth) and ruling out (??even again) that there is NOT something other than or in addition to Asthma going on.

Finally remeber that not all Asthma Patients respond to ICS equally---see the new GINA Guidelines on Heterogenity.

Good Luck

thank you so much, this helps me look at this differently :)

First you have to check the compliance of tha patient, second to check the technical method of inhaling. If the FeNO in high there is an indication to add to the ICS: Singulair (Montelucast) . According to GINA guidlines to increase the dosage of the ICS (not above the recomended dose) and/or to add LABA. Rememeber always the FDA warning about long time LABA treatment. If no significant improvement will be achieved, there is a need to find out if there is a GER, ABPA,  or other causes of "asthma like apearance". There are the asthma phenotypes which are ICS resistant.

Good Luck 

There is no perfect answer to this question for all subjects.

Different studies have shown that addition of either of these agents, or even an anticholinergic therapy such as tiotropium, can be effective as add-on therapy. 

One strategy is to try to identify predictive biomarkers, such as exhaled NO, or blood or sputum eosinophils. For many of these patients who have increased levels of these,, increasing the dose of inhaled corticosteroids is often beneficial.

In the acute setting, when a patient is poorly controlled, I try to get them under better control and i often do both, increase the dose of the inhaled corticosteroid AND add a long acting beta agonist. Once well controlled, I will step them down sequentially.