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Consider severity and interval since last exacerbation Progressive loss of lung function Evaluation requires long-term followup care Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended action for treatment • Maintain current step • Regular followups every one to six months to maintain control • Consider step down if well controlled for at least three months • Step up 1 step and • Reevaluate in two to six weeks • For side effects, consider alternative treatment options • Consider short course of oral systemic glucocorticoids, • Step up 1 to 2 steps, and • Reevaluate in two weeks • For side effects, consider alternative treatment options The stepwise approach is meant to assist, not replace, the clinical decision-making required to meet individual patient needs. The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient's recall of previous two to four weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. At present, data are inadequate to correlate frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had >2 exacerbations requiring oral systemic glucocorticoids in the past year may be considered the same as patients who have not-well-controlled asthma even in the absence of impairment levels consistent with not-well-controlled asthma. Validated questionnaires for the impairment domain (the questionnaires do not assess lung function or the risk domain): - ATAQ: Asthma Therapy Assessment Questionnaire - ACQ: Asthma Control Questionnaire (user package may be obtained at www.qoltech.co.uk or juniper@qoltech.co.uk) - ACT: Asthma Control Test Minimal important difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.

Before step up in therapy: - Review adherence to medication, inhaler technique, environmental control, and comorbid conditions. - If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step. EIB: exercise-induced bronchospasm; FEV 1 : forced expiratory volume in one second; ICU: intensive care unit; N/A: not applicable. * ACQ values of 0.76 to 1.4 are indeterminate regarding well-controlled asthma. Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.