Proposed practical guidelines for adjusting maintenance medications during acute loss of asthma control

RecommendationRationaleSupporting evidence
Maintain the controller medication as part of the “yellow zone” dose, where possibleReinforces that “green zone” controller medications are never to be stopped and minimises chances of the patient continuing with the incorrect puffer after yellow zone treatment is completeAdherence shown to decrease when maintenance medications are changed [31, 32]
Add additional inhalations while maintaining the baseline controller medication frequency, where possibleMinimises dosing frequency, maintains consistency with the controller regimen, thereby minimising medication errors and maximising adherenceAdherence shown to be inversely correlated with dosing frequency [33, 34]
Increase the number of inhalations of the baseline controller medication to attain the target dose rather than prescribing an additional inhaler, where possibleMinimises cost and complexity of filling a new inhaler prescription and maximises adherenceAdherence shown to decrease when new inhalers are added or more than one inhaler is recommended [35, 36]
When it is necessary to add a new inhaler in the “yellow zone,” use the same device type as the baseline controller medicationMaintains consistency with the baseline controller medication, thereby minimising medication administration errors and maximises adherenceAdherence and asthma control shown to worsen when device type is changed [31]
Do not exceed 4 inhalations per use, and in cases where it is necessary to add a new puffer in the yellow zone, use a dose which favours the least number of inhalations per useEnsures practical applicability of yellow zone regimen, thereby maximising adherenceMDI and DPI inhalers require up to 1 min per puff [36]
More than 4 min per use is not practical and may decrease adherence (expert opinion)
Consider patient-relevant issues such as medication cost and product shelf-life, particularly when proposing a requirement for new prescriptions in the “yellow zone”Excessive cost of treatment and the possibility of medication waste may negatively affect adherenceAdherence has been shown to be inversely correlated with socioeconomic status and income in some studies [36]

MDI: metered dose inhaler; DPI: dry powder inhaler.