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Asthma Prevention and Control Medications

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 1: Stepwise approach to asthma management for adults and children 12 years and up1

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 4/29/19 at: National Heart, Lung, and Blood Institute

Figure 2: Stepwise approach to asthma management for children ages 5-111


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 4/29/19 at: National Heart, Lung, and Blood Institute

Figure 3: Stepwise approach to asthma management for children ages 0-41


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 4/29/19 at: National Heart, Lung, and Blood Institute

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

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. Several of these include, but are not limited to, Aerospan (flunisolide), Alvesco (ciclesonide), and Pulmicort (budesonide).4 Your doctor or healthcare provider will help you determine which inhaled corticosteroids are most appropriate in your situation.

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 1).1,5,6

Table 1. 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 4/29/19 at: National Heart, Lung, and Blood Institute; 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. Although LABA treatment may not be permanent, it’s important not to stop or change the dose of any medication without talking to your healthcare provider first.

Which medications are LABAs?

LABAs are packaged alone or in combination inhalers with a corticosteroid. Medications like Serevent (salmeterol) may be packaged alone, however, they should always be taken with a second, separate asthma medication.

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

As mentioned, combination inhalers contain an inhaled corticosteroid and a LABA. Some common combination inhalers include Advair (fluticasone propionate/salmeterol), Dulera (mometasone/formoterol fumarate), Symbicort (budesonide/formoterol fumarate), and Breo (fluticasone fuorate/vilanterol). This is not an exhaustive list of all combination inhalers. Your doctor or healthcare provider will help you determine which options are appropriate in your situation.7

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 antagonists.”

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 several leukotriene modifiers, including Singulair (montelukast), Accolate (zafirlukast), and Zyflo (zileuton).4

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 2-4). 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 in individuals with the most severe asthma. (Step 6)1

Long-term use of oral corticosteroids has many serious side effects.1 The short-term side effects generally go away after stopping the medication. These side effects include changes in blood sugar, increased appetite, fluid retention, insomnia, upset stomach, and high blood pressure.

Several side effects of long-term oral corticosteroid use include:

  • Stunted growth
  • High blood pressure
  • Cataracts
  • Bruising and skin effects
  • Muscle weakness
  • Diabetes
  • Osteoporosis
  • Cushing syndrome (high cortisol level)
  • Adrenal suppression (the hormone-secreting glands on top of the kidneys)
  • Impaired immune system

Biologics (immunotherapy)

Biologics are a new group of medications that target a specific molecule, cell, or antibody that is thought to be involved in asthma and its symptoms. In asthma treatment, some of these targets include cells or molecules involved in the inflammatory response. Biologics targets are so specific and tailored to the condition they’re treating, that they are sometimes called “personalized” or “precision” therapy. The medication itself is made from living cells that can come from a mouse, bacteria, or humans. All biologics are delivered via an injection under the skin or as an infusion into a vein.12

When are biologics prescribed?

Biologics are not considered a first-line treatment for asthma. Instead, they are used for moderate to severe asthma that is not well controlled, even after the use of daily controller medications. Individuals who are regularly admitted to the hospital, use a rescue inhaler several times a day or week, or who are taking oral steroids may be eligible for treatment with a biologic medication.

What medications are biologics?

There are several biologic medications on the market for asthma. These include, omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Omalizumab targets IgE, a molecule involved in the allergic response, and dupilumab blocks the action of several interleukins (molecules involved in the inflammatory response). The other three biologics target eosinophils, a cell that is highly involved in inflammatory and allergic responses within the body. Some biologics are indicated for use in children. Your healthcare provider will help you determine which biologic may be appropriate for you.12

What are the risks of taking biologics?

The most common side effect of biologics is an increased risk of infection. Other common side effects are headache, sore throat, fatigue and soreness at the injection or infusion site. Omalizumab may increase an individual’s risk of developing anaphylaxis. Anaphylaxis is a whole-body allergic reaction that can cause airway narrowing, low blood pressure, fainting, hives or swelling. Some biologics, like mepolizumab, may require that you are up to date on certain vaccinations before starting treatment.12

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

Immunotherapy is done to make you less sensitive to certain allergens.13 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 recent years, the US Food and Drug Administration has approved under-the-tongue allergy treatments for certain allergies, including dust mites, Timothy and similar grasses, and ragweed.13

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.13 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.

Written by: Sarah O'Brien | Last Reviewed: September 2019.
  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. American Academy of Allergy, Asthma, and Immunology. Biologics for the Management of Severe Asthma. Accessed 4/29/19 at https://www.aaaai.org/conditions-and-treatments/library/asthma-library/biologics-asthma.
  13. American Academy of Allergy, Asthma, and Immunology. Allergy Shots (Immunotherapy). Accessed 4/29/19 at: http://www.aaaai.org/conditions-and-treatments/library/allergy-library/allergy-shots-%28immunotherapy%29.aspx.