Asthma Medicine: Finding What Works Best For You
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There are various terms describing asthma medicines. Here I will define these terms for you, along with what asthma medicines they are referring to. Ideally, this should give you an idea of what medicines are available to you and your doctor in your quest to obtaining ideal asthma control.

Traditional Medicine

These are medicines that are scientifically proven safe and effective for preventing and controlling asthma. They are approved by the FDA, recommended by asthma guidelines, and prescribed by physicians as standard asthma treatments.

First-line Medicine

These are referred to as top-line, front-line, standard, or traditional asthma medicines. These are usually the first medicines prescribed once a diagnosis of asthma is made. They help most asthmatics treat, prevent, and control their asthma. They include rescue medicine and controller medicine.

Rescue Medicine

These are medicines that act to quickly open airways to relieve asthma symptoms and end asthma attacks. Most asthma experts recommend that all asthmatics have a prescription for a rescue medicine, and that they keep it nearby at all times. They include:

  • Short Acting Beta-2 (B2) Adrenergic (SABA) Inhalers These are inhaled medicines that attach to B2 adrenergic receptors lining your air passages to open airways and make breathing easier. They usually work fast, which is why they are often called rescue medicines, although they are short acting, usually lasting 4-8 hours. These include albuterol (Ventolin, ProAir, Proventil) and levalbuterol (Xopenex).

Controller Medicine

These are medicines that are taken every day to prevent and control asthma. They are also referred to as asthma maintenance medicines. They include:

  • Inhaled corticosteroids These inhalers contain a low dose of corticosteroids that, once inhaled, attach to cells lining airways to reduce airway inflammation. This makes your airways less sensitive to asthma triggers to prevent asthma attacks, or make them less severe when they do occur. These include fluticasone (Flovent HFA, Arnuity Ellipta), beclomethasone (Qvar), flunisolide (Aerospan), ciclesinide (Alvesco HFA), mometasone (Azmanex HFA, Azmanex Diskus), and budesonide (Pulmicort Flexhaler).
  • Inhaled corticosteroid/ Long-Acting B2 Adrenergic Combination Inhalers. These are inhalers that contain an inhaled corticosteroid and a LABA. LABA’s are B2 adrenergic medicines that last 12-24 hours. They are given in conjunction with an inhaled corticosteroid to keep airways open long term. They are what is prescribed when inhaled corticosteroids alone do not result in optimal asthma control. Examples include: fluticasone/ salmeterol (Advair Diskus, Advair HFA), fluticasone/ vilanterol (Breo Ellipta), mometasone/ formoterol (Dulera), and budesonide/ formoterol (Symbicort HFA)

Second-line Medicine

These are also considered traditional asthma medicines, although they are usually referred to as add-ons or adjunct medicines. They include:

  • Leukotriene Modifiers. They block the effects of leukotrienes, which are chemicals released during the asthma/ allergy response that cause allergy and asthma symptoms. Examples include montelukast (Singulair),  zafirlukast (Accolate), and zileuton (Zyflo).
    • Anticholinergics They block the effects of acetylcholine, which is a neurotransmitter that causes bronchoconstriction. Examples include ipatropium bromide (Atrovent HFA), glycopyrrolate, (Seebri Neohaler), umeclidinium (Incruse Ellipta), tiotropium bromide (Spiriva HandiHaler), (Spiriva Respimat), and aclidinium bromide (Tudorza Pressair).
  • Anticholinergic/ B2 Adrenergic Combination Inhalers These include ipatropium bromide/ albuterol (Combivent Respimat).
  • Combination Anticholinergic/ LABA Inhalers These include umeclidinium/ vilanterol (Anoro Ellipta), tiotropium bromide/ olodaterol (Stiolto Respimat), and glycopyrrolate/ indacaterol (Utibron Neohaler).
  • LABA Inhalers These are not generally recommended for use with asthma without also using an inhaled corticosteroid. However, they are still options. These include salmeterol (Serevent Diskus), indacaterol (Arcapta Neohaler), and olodaterol (Striverdi Respimat).
  • Methylxanthines These are little white pills that were considered first-line asthma medicines back in the 1970’s and 80’s. They are good bronchodilators, although they also appear to have some anti-inflammatory properties. Today they are considered as second-line, adjunct, or alternative medicines mainly because of side effects and due to better medicines on the market today for controlling asthma. The most common one prescribed here is theophylline. They have been around for a long time, so there are various generic products available.
    • Systemic Corticosteroids These are corticosteroids that are taken orally and can be used to reduce airway inflammation to control acute asthma episodes. Usually you are given a bolus dose on the first day, and then you are weaned off them over the course of several days. To reduce your risk for side effects, your doctor will usually try to keep the dose as low as possible, and the duration as short as possible. Examples include methylprednisolone, prednisolone, and prednisone.
  • Biologics (Immunomodulators, monoclonal antibodies). These are medicines that block the effects of certain immune cells and chemicals responsible for asthma and allergy symptoms. Examples include omalizumab (Xolair), mepolizumab (Nucala) and reslizumab (Cinqair).

Adjunct Medicine

These are second-line medicines that are used in conjunction with first-line medicine, especially when first-line medicines do not result in ideal asthma control. An example here is when an allergic asthmatic is prescribed Advair and Albuterol yet still has allergy symptoms. A good adjunct therapy here might be Singulair.

Alternative Medicine

These are second-line medicines that are used instead of first-line medicines in an effort to obtain ideal asthma control. A good example here is prescribing Singulair to control asthma in a person who has exercise-induced asthma. In some individuals, Singulair alone might work for this.

Non-Traditional Treatment

These are asthma treatments that are not well studied and therefore not generally recommended by the medical profession. However, some asthmatics find they are used as alternatives to, or adjuncts with, traditional asthma medicines. They include changing your diet to include certain vitamins, minerals, and supplements. Halotherapy (salt therapy), breathing exercises (Yoga, Buteyko), acupuncture, chiropractic services, and homeopathy are also included here.

Pipeline

These are medicines that are currently being developed or studied to see if they are viable and safe treatments for asthma. At the present time, there are a variety of asthma medicines in the pipeline, including the biologics benralizumab, ligelizumab, tralokinumab, lebrikizumab, dupilumab, and dectrekumab.

Conclusion

Once you have a diagnosis of asthma, and once your doctor determines you might benefit from asthma medicines, finding which medicine or medicine combinations work best for you is usually a matter of trial and error.

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