From the Guidelines
Inhaled corticosteroids are the preferred first-line controller medications for asthma during pregnancy, with budesonide being the most recommended due to its extensive safety data. The primary goal during pregnancy is maintaining good asthma control, as uncontrolled asthma poses greater risks to both mother and fetus than potential medication side effects 1.
Key Considerations for Asthma Management in Pregnancy
- Inhaled corticosteroids (ICS) are the preferred long-term control medication, with budesonide having the most safety data, though other ICS options like fluticasone and beclomethasone are also considered safe 1.
- For women with mild persistent asthma, low-dose ICS therapy is recommended, while those with moderate persistent asthma may require medium-dose ICS.
- If asthma is not adequately controlled with ICS alone, adding a long-acting beta-agonist (LABA) like salmeterol or formoterol is the preferred next step 1.
- Inhaled cromolyn sodium is considered safe but less effective than ICS.
- Oral theophylline can be used as an alternative controller but requires monitoring of blood levels (target 5-12 μg/mL) and may cause nausea 1.
- Leukotriene receptor antagonists (montelukast, zafirlukast) have limited pregnancy safety data and are generally considered second or third-line options.
Monitoring and Adjustments
Regular monitoring of asthma symptoms during pregnancy is essential, with adjustments to therapy as needed to maintain control 1. Rescue medication with short-acting beta-agonists like albuterol is safe when needed for symptom relief. The course of asthma improves in 1/3 of women and worsens for 1/3 of women during pregnancy, making monthly evaluations of asthma crucial to step up therapy if necessary and to step down therapy if possible 1.
From the Research
Preferred Asthma Agents During Pregnancy
The preferred asthma agents during pregnancy are:
- Inhaled corticosteroids (ICSs) 2
- Inhaled cromolyn (cromolyn sodium) is not mentioned in the provided studies as a preferred agent during pregnancy
- Oral theophylline is not recommended as a first-line treatment, as inhaled long-acting beta-agonists are more effective in controlling asthma symptoms than theophylline 3
- Oral leukotriene receptor antagonists (LTRAs) may be considered as add-on therapy to ICSs, but are less effective than long-acting beta-agonists (LABAs) in preventing exacerbations and improving lung function 4, 5, 6
- Long-acting beta-agonists (LABAs) are effective in achieving asthma control when combined with ICSs, and are preferred over LTRAs as add-on therapy to ICSs 4, 5, 3, 6
Key Findings
- Inhaled corticosteroids (ICSs) are safe for pregnant women with asthma and their infants 2
- LABAs are superior to LTRAs in reducing oral steroid-treated exacerbations, and have a modest advantage in improving lung function, functional status, and quality of life scores 5, 6
- The combination of LABA and ICS is more effective than the combination of LTRA and ICS in preventing exacerbations and improving asthma control 4, 5, 6
- The use of a single inhaler for the delivery of LABA and ICS is supported by the findings 6