What are alternative treatments for asthma when inhalers are not tolerated?

From the Guidelines

Alternative treatments for asthma when inhalers are not tolerated include oral medications, biologics, and non-pharmacological approaches, with a focus on personalized management to improve morbidity, mortality, and quality of life. When considering treatment options, it's crucial to prioritize the most recent and highest quality evidence, which may not always be directly applicable but guides clinical decision-making. According to the most recent study 1, achieving optimal asthma control requires a stepwise approach to pharmacological treatment, considering the complexity of overlapping disorders, comorbidities, and lifestyle/environmental factors that can impact asthma management. Some key alternatives include:

• Oral medications such as leukotriene modifiers (e.g., montelukast 10mg daily) and theophylline (starting at 300mg daily, adjusted based on blood levels), which can help control symptoms by blocking inflammatory chemicals and relaxing airway muscles, respectively 1.
• Biologic injections like omalizumab (Xolair), which can be used as adjunctive therapy for patients with severe persistent asthma who have sensitivity to relevant allergens 1.
• Non-pharmacological approaches, including breathing exercises, avoiding triggers, maintaining a clean living environment, and using air purifiers, which can help reduce symptom severity and improve quality of life. It's essential to work closely with a healthcare provider to find the right treatment approach, as asthma management should be personalized based on symptom severity, triggers, and individual response to treatments, with the goal of minimizing morbidity, mortality, and maximizing quality of life.

From the FDA Drug Label

Patients who have exacerbations of asthma after exercise should have available for rescue a short-acting inhaled β-agonist. While the dose of inhaled corticosteroid may be reduced gradually under medical supervision, SINGULAIR should not be abruptly substituted for inhaled or oral corticosteroids Therapy with SINGULAIR can be continued during acute exacerbations of asthma Patients should be advised to have appropriate rescue medication available.

Alternative treatments for asthma when inhalers are not tolerated include:

• Oral medications such as montelukast (SINGULAIR) 2
• Theophylline (PO) 3, which has been shown to decrease the frequency and severity of symptoms in patients with chronic asthma.

Key points to consider when using these alternative treatments:

• Patients should have appropriate rescue medication available, such as a short-acting inhaled β-agonist.
• Dose reduction and frequent monitoring of serum concentrations are required in certain patient populations, such as those with reduced hepatic function or congestive heart failure.
• Medical supervision is necessary when reducing the dose of inhaled corticosteroids or oral corticosteroids.

From the Research

Alternative Treatments for Asthma

When inhalers are not tolerated, there are several alternative treatments for asthma that can be considered. These include:

• Oral corticosteroids (OCS) [ 4 ], which can be used as a maintenance therapy to control asthma symptoms, but their long-term use is associated with several comorbidities
• Biologics, such as omalizumab, mepolizumab, benralizumab, and dupilumab [ 4 ], which can reduce the need for OCS and improve patient-related outcomes
• Oral leukotriene receptor antagonists, such as zafirlukast [ 5 ], which can be used as a maintenance therapy and have demonstrated efficacy in improving pulmonary function and reducing symptoms
• 5-lipoxygenase inhibitors, such as zileuton [ 5 ], which can also be used as a maintenance therapy and have demonstrated efficacy in improving pulmonary function and reducing symptoms

Non-Steroidal Treatments

Non-steroidal treatments, such as leukotriene modifiers, can also be used to treat asthma. These include:

• Montelukast, zafirlukast, and zileuton [ 6 ], which have been shown to improve pulmonary function, reduce symptoms, and decrease the need for rescue medications
• Pranlukast [ 6 ], which is available in Japan and has been shown to be effective in improving pulmonary function and reducing symptoms
• CysLT(1) receptor antagonists [ 7 ], which can be given orally as monotherapy in patients with mild persistent asthma and may improve asthma control when combined with inhaled glucocorticoids

Other Options

Other options for treating asthma when inhalers are not tolerated include:

• Nedocromil and cromolyn [ 8 ], which possess significant anti-inflammatory effects and can be used as a maintenance therapy
• Theophylline and beta agonists [ 8 ], which possess some anti-inflammatory effects and can be used as a maintenance therapy
• Anti-IgE, gold, nebulized lidocaine, cyclosporine, intravenous immunoglobulin, methotrexate, hydroxychloroquine, dapsone, and troleandomycin [ 8 ], which have been shown to have anti-inflammatory effects and may be used as corticosteroid sparing agents.