Asthma Prevention and Control Medications

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The main treatment for asthma is using control medications each day.1 The asthma control medications used most often reduce inflammation in your airways.1 When the airways are less inflamed, they become less sensitive (“hyperresponsive”). This reduces your risk of having an asthma attack.1 You may need one or more medications to get your asthma under control.

Control medications do not work quickly enough to treat an asthma attack. If you are having an asthma attack, you will need to use a rescue inhaler to open up your airways rapidly.

Stepwise approach to treating asthma

The National Heart, Lung, and Blood Institute recommends a stepwise approach to asthma treatment (Figure).1 Your provider will prescribe medication based on how intense your asthma is at first. If the medication is not enough to control your asthma, your treatment goes up one step. This could mean increasing the dose or adding a medication. If your asthma is well controlled for at least three months, you may be able to go down one step. Your health care provider may recommend trying a lower dose or cutting out a medication to see if your asthma stays under control.

Figure. Stepwise approach to asthma management (for adults and children 12 years and up)

The NHLBI guidelines also note alternative medications for steps 2 through 6. The alternatives have not been included in this figure.

Adapted from: National Heart Lung and Blood Institute. Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma – Full Report 2007. Accessed 11/12/14 at: http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf;pg 343

Inhaled corticosteroids

Many studies have shown that inhaled corticosteroids are the most effective medications for long-term asthma control.1 Inhaled corticosteroids make your airways less inflamed. This leads to less severe asthma symptoms and better lung function. The airways become less sensitive. Therefore, the risk of having an asthma attack is lower. You are less likely to need to visit the emergency department if you take inhaled corticosteroids.

When are inhaled corticosteroids prescribed?

Inhaled corticosteroids are the backbone of asthma treatment for most adults and children with persistent asthma.1 Inhaled corticosteroids usually work well for people with allergic asthma.2 Inhaled corticosteroids do not work as well for smokers or people who are obese. They are also less effective for some types of adult-onset asthma.1-3

Which medications are inhaled corticosteroids?

There are several inhaled corticosteroids available (Table 1).4

Table 1. Inhaled corticosteroids

Brand Name
Generic Name
Aerospan
Flunisolide
Alvesco
Ciclesonide
Arnuity Ellipta
Fluticasone furoate
Asmanex
Mometasone furoate
Flovent
Fluticason Propionate
Pulmicort
Budesonide
QVAR
Beclomethasone dipropionate

Adapted from: American Academy of Allergy, Asthma, and Immunology. Allergy and Asthma Drug Guide. Accessed 2/13/15 at: http://www.aaaai.org/conditions-and-treatments/drug-guide.aspx

What are the risks of taking inhaled corticosteroids?

According to the National Heart, Lung, and Blood Institute, the benefits of taking inhaled corticosteroids outweigh the risks (Table 2).1,5,6

Table 2. Potential risks of inhaled corticosteroids

Risk
Population and Frequency
Treatment/Prevention
Thrush (oral fungal infection)
More common in adults than children; rare with low doses, frequency 0%-77%.1,5
Use a spacer or valved holding chamber with your inhaler. Rinse your mouth with water after taking your medication.
Slower growth
Small effect in children: rate of growth is slower by 0.19 inches (0.48 centimeters) per year with low- or medium-dose inhaled corticosteroid.6 Children with asthma are not shorter as adults than children without asthma.5
Monitor growth; use the lowest dose of medication needed to keep your child’s asthma under control.1
Lower bone density
May affect adults after long-term use. Does not affect children.1,5
Measure bone density every 1-2 years, consider taking medications for osteoporosis.1
Hoarseness and cough5
Hoarseness: 5% to 50%; Cough: 35%
Use a spacer or valved holding chamber with your inhaler.
Easy bruising
Effect depends on dose, duration of treatment, and gender.
Cataracts
Effect depends on dose, duration of treatment, and gender.

National Heart, Lung, and Blood Institute. Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma – Full Report 2007. Accessed 11/12/14 at: http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf; pgs 221-222; Irwin RS, Richardson ND. Chest. 2006;130(1 Suppl):41S-53S; Zhang L, et al. Cochrane Database Syst Rev. 2014;7:CD009471.

Long-acting beta agonists

Long-acting beta agonists relax the muscles that surround the airways. The effects last for up to 12 hours after taking a dose. Long-acting beta agonist is abbreviated LABA.

When are LABAs prescribed?

LABAs are used together with inhaled corticosteroids. They are used to treat people with moderate to severe asthma. LABAs reduce asthma symptoms, asthma attacks, and rescue medication use.1 They work well for people with exercise-induced asthma.

For safety reasons, LABAs cannot be used alone.7 They must be used with another long-term control medication, such as inhaled corticosteroids. If a low-dose or medium-dose inhaled corticosteroid is enough to control your asthma, you should not use a LABA. If you are taking a LABA, your health care provider may ask you to stop for a period of time.  The goal of stopping is to see if your asthma stays controlled without it.

Which medications are LABAs?

LABAs are packaged alone or in combination inhalers with a corticosteroid. Table 3 has a list of the LABA-only products.7 These should be taken with a second, separate asthma medication.

Table 3. Long-acting beta agonists

Brand Name
Generic Name
Foradil
Formoterol
Serevent
Salmeterol

US Food and Drug Administration. FDA Drug Safety Communication: Drug labels now contain updated recommendations on the appropriate use of long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs). Accessed 2/13/15 at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213836.htm

What are the risks of taking LABAs?

In large trials, people treated with LABAs had a higher risk of severe asthma attacks and asthma-related death.7 The US Food and Drug Administration (abbreviated FDA) required drug companies to add a warning about this risk on all LABAs.

The FDA says that when the LABAs are used correctly, the benefits outweigh the risks.7

Combination inhalers

Combination inhalers contain an inhaled corticosteroid and a LABA (Table 4).7 Just like LABA-only medications, there is an increased risk of severe asthma attacks and asthma-related death with these medications.

Table 4. Combination inhalers

Brand Name
Inhaled Corticosteriod
LABA
Advair
Fluticasone propionate
Salmeterol
Dulera
Mometasone
Formoterol fumarate
Symbicort
Budesonide
Formoterol fumarate

US Food and Drug Administration. FDA Drug Safety Communication: Drug labels now contain updated recommendations on the appropriate use of long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs). Accessed 2/13/15 at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213836.htm

Leukotriene modifiers

Leukotriene modifiers are tablets that are taken by mouth.1 These medications block signaling chemicals called “leukotrienes.” Leukotrienes cause the airways to become narrow and sensitive. Another term used to describe some leukotriene modifiers is “leukotriene receptor agonists.”

When are leukotriene modifiers prescribed?

Leukotriene modifiers do not work as well as inhaled corticosteroids.8 Leukotriene receptor agonists can be used as alternatives to inhaled corticosteroids for people with mild to moderate asthma (Step 2).1 Leukotriene modifiers can also be used in addition to inhaled corticosteroids for moderate asthma (Steps 3 and 4).

Leukotriene modifiers are sometimes used to treat exercise-induced asthma and aspirin-induced asthma.1,2,9 These medications may also be good for treating asthma-related cough.10

Which medications are leukotriene modifiers?

The FDA has approved three leukotriene modifiers (Table 5).4

Table 5. Leukotriene modifiers

Brand Name
Generic Name
Singulair
Montelukast
Accolate
Zafirlukast
Zyflo
Zileuton

Adapted from: American Academy of Allergy, Asthma, and Immunology. Allergy and Asthma Drug Guide. Accessed 2/13/15 at: http://www.aaaai.org/conditions-and-treatments/drug-guide.aspx

What are the risks of taking leukotriene modifiers?

All the leukotriene modifiers have a warning that they can cause changes in mood or behavior.11 Zafirlukast and zileuton may affect the liver. They also interact with other common drugs.1,8

Theophylline

Theophylline is an oral medication. It relaxes the airways and it may reduce airway inflammation.1 It is an alternative to inhaled corticosteroids for mild asthma (Step 2). However, inhaled corticosteroids work better. Theophylline can also be used in combination with inhaled corticosteroids to treat moderate to severe asthma. Accidental theophylline overdose can occur. Signs of an overdose are nausea and vomiting.

Oral corticosteroids

Oral corticosteroids reduce inflammation. These medications include methylprednisolone, prednisolone, and prednisone.1 They may be used short-term at the start of an asthma attack or after an attack.1 Because of the risk of side effects, they are only used long-term use to treat patients with the most severe asthma (Step 6).1

Long-term use of oral corticosteroids has many serious side effects (Table 6).1 The short-term side effects generally stop after stopping the medication. These side effects include changes in blood sugar, increased appetite, fluid retention, and high blood pressure.

Table 6. Side effects of long-term oral corticosteroid use

  • Stunted growth
  • High blood pressure
  • Cataracts
  • Bruising and skin effects
  • Muscle weakness
  • Diabetes
  • Osteoporosis
  • Cushing syndrome (high cortisol level)
  • Adrenal suppression
  • Impaired immune system

Adapted from: National Heart, Lung, and Blood Institute. Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma – Full Report 2007. Accessed 11/12/14 at: http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf;pg243

Omalizumab (Xolair)

Omalizumab (brand name: Xolair) is an injectable medication. It works by blocking IgE. IgE is an antibody that is responsible for many allergy symptoms.1,12

Omalizumab is used to treat moderate to severe allergic asthma when high-dose inhaled corticosteroids and a LABA are not enough (Step 5 and 6).1 It is approved for adults and children ages 12 and up. The injections are taken every two or four weeks.13

Anaphylaxis is rare but life-threatening side effect of omalizumab.13 Anaphylaxis is a whole-body allergic reaction that can cause airway narrowing, low blood pressure, fainting, hives or swelling.

Allergy shots and under-the-tongue allergy treatments (Immunotherapy)

Immunotherapy is done to make you less sensitive to certain allergens.14 You start by taking a very small dose of an allergen. The dose increases over time. A course of allergy shots can take three to five years.1 During that time, your body builds up a tolerance to the allergen. Immunotherapy is most useful when there is a clear link between an allergen and symptoms.1 It is most helpful for treating grass, cat, dust-mite, and ragweed allergies.1 It is less helpful for cockroach or mold allergies.

Allergy shots used to be the only option for immunotherapy. However, in 2014 the US Food and Drug Administration approved under-the-tongue allergy treatments for certain grass allergies.15

The main risk of allergy shots is a life-threatening reaction. For this reason, allergy shots are given in a doctor’s office. This type of reaction is rare.  The under-the-tongue allergy treatment should be taken in a doctor’s office the first time, in case of a reaction.15 Afterward, the tablet is taken at home once a day. Treatment starts a few months before allergy season and continues until the end of the season.

view references
  1. National Heart, Lung, and Blood Institute. Expert panel report 3 (EPR-3): Guidelines for the diagnosis and management of asthma - Full Report 2007. Accessed 11/12/14 at: http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf/
  2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2014. Accessed 11/12/14 at: www.ginasthma.org.
  3. Wenzel SE. Asthma phenotypes: the evolution from clinical to molecular approaches. Nat Med. 2012;18:716-725. http://www.ncbi.nlm.nih.gov/pubmed/22561835
  4. American Academy of Allergy, Asthma, and Immunology. Allergy and Asthma Drug Guide. Accessed 2/13/15 at: http://www.aaaai.org/conditions-and-treatments/drug-guide.aspx
  5. Irwin RS, Richardson ND. Side effects with inhaled corticosteroids: the physician's perception. Chest. 2006;130(1 Suppl):41S-53S. http://journal.publications.chestnet.org/data/Journals/CHEST/22046/41S.pdf
  6. Zhang L, Prietsch SO, Ducharme FM. Inhaled corticosteroids in children with persistent asthma: effects on growth. Cochrane Database Syst Rev. 2014;7:CD009471. http://www.ncbi.nlm.nih.gov/pubmed/25030198
  7. US Food and Drug Administration. FDA Drug Safety Communication: Drug labels now contain updated recommendations on the appropriate use of long-acting inhaled asthma medications called Long-Acting Beta-Agonists (LABAs). Accessed 2/13/15 at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213836.htm
  8. Scow DT, Luttermoser GK, Dickerson KS. Leukotriene inhibitors in the treatment of allergy and asthma. Am Fam Physician. 2007;75:65-70. http://www.aafp.org/afp/2007/0101/p65.html
  9. Corren J. Asthma phenotypes and endotypes: an evolving paradigm for classification. Discov Med. 2013;15:243-249. http://www.discoverymedicine.com/Jonathan-Corren/2013/04/26/asthma-phenotypes-and-endotypes-an-evolving-paradigm-for-classification/
  10. Dicpinigaitis PV. Chronic cough due to asthma: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 Suppl):75S-79S. http://journal.publications.chestnet.org/data/Journals/CHEST/22039/75S.pdf
  11. US Food and Drug Administration. FDA requests labeling change for leukotriene modifiers. Accessed 2/13/15 at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm166293.htm
  12. Asthma and Allergy Foundation of America. IgE's role in allergic asthma. Accessed 2/13/15 at: http://www.aafa.org/display.cfm?id=8&sub=16&cont=54
  13. Xolair® [prescribing information]. South San Francisco, CA: Genentech, Inc; 2014.
  14. American Academy of Allergy, Asthma, and Immunology. Allergy Shots (Immunotherapy). Accessed 2/13/15 at: http://www.aaaai.org/conditions-and-treatments/library/allergy-library/allergy-shots-%28immunotherapy%29.aspx
  15. US Food and Drug Administration. FDA approves first sublingual allergen extract for the treatment of certain grass pollen allergies. Accessed 1/6/15 at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391458.htm
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