A 28-year-old woman with mild persistent asthma presents to the clinic with complaints of wheezing 3–4 times per week and nocturnal symptoms twice monthly. She is currently on salbutamol as needed. Spirometry shows FEV₁ 78% of predicted. What is the most appropriate next step in management?

## Classification and Stepwise Therapy **Key Point:** This patient meets criteria for mild persistent asthma (symptoms >2 days/week but <daily, nocturnal symptoms 1–2 times/month, FEV₁ 60–80% predicted). According to GINA and Indian guidelines, mild persistent asthma requires regular controller therapy. **High-Yield:** The stepwise approach to asthma management is: - Step 1 (Intermittent): SABA only - Step 2 (Mild persistent): Low-dose ICS as regular maintenance - Step 3 (Moderate persistent): Low-dose ICS/LABA or medium-dose ICS - Step 4 (Severe persistent): High-dose ICS/LABA ± LTRA ## Why ICS is the Correct Choice **Clinical Pearl:** Inhaled corticosteroids are the most effective anti-inflammatory agents for asthma and are the gold standard for all levels of persistent asthma. Starting ICS at Step 2 prevents disease progression and reduces exacerbation risk. **Key Point:** ICS monotherapy (not combination therapy) is indicated when: - Asthma is mild persistent - Patient is not on LABA - FEV₁ is >60% predicted Combination ICS/LABA is reserved for Step 3 and above (moderate to severe persistent asthma). ## Dosing Recommendation | ICS Agent | Low Dose (μg/day) | Medium Dose (μg/day) | High Dose (μg/day) | | --- | --- | --- | --- | | Beclomethasone | 200–400 | 400–800 | >800 | | Budesonide | 200–400 | 400–800 | >800 | | Fluticasone | 100–200 | 200–500 | >500 | For this patient: **Low-dose ICS inhaler, 1–2 puffs twice daily, is appropriate.** **Mnemonic:** GINA Steps = **SABA → ICS → ICS/LABA → Add LTRA/LAMA** **Tip:** Always counsel on proper inhaler technique and review after 2–4 weeks to assess response before escalating.