What medications are used for the management of asthma?

Medications for Management of Asthma

Inhaled corticosteroids (ICS) are the most consistently effective long-term control medication for persistent asthma at all steps of care, and should be the first-line controller treatment for all patients with persistent asthma. 1

Classification of Asthma Medications

Asthma medications fall into two main categories:

1. Long-Term Control Medications

• Inhaled Corticosteroids (ICS)

  • First-line therapy for persistent asthma
  • Examples: fluticasone propionate, budesonide
  • Mechanism: Anti-inflammatory medications that reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation
  • ICS improve asthma control more effectively than any other single medication 1

• Long-Acting Beta2-Agonists (LABAs)

  • Not to be used as monotherapy
  • Must be combined with ICS
  • Examples: salmeterol, formoterol
  • Used as preferred combination therapy with ICS for moderate and severe persistent asthma 1

• Leukotriene Modifiers

  • Alternative (not preferred) therapy for mild persistent asthma
  • Examples: montelukast, zafirlukast (LTRAs), zileuton (5-lipoxygenase inhibitor)
  • Can be used as adjunctive therapy with ICS for moderate persistent asthma 1

• Cromolyn Sodium and Nedocromil

  • Alternative (not preferred) medications for mild persistent asthma
  • Mechanism: Stabilize mast cells and interfere with chloride channel function
  • Can be used as preventive treatment before exercise or allergen exposure 1

• Immunomodulators

  • Omalizumab (anti-IgE): Used as adjunctive therapy for patients ≥12 years with severe persistent asthma and sensitivity to relevant allergens 1

• Methylxanthines (Theophylline)

  • Alternative therapy for mild persistent asthma
  • Requires monitoring of serum levels 1

2. Quick-Relief Medications

• Short-Acting Beta2-Agonists (SABAs)

  • Primary rescue medication for acute symptom relief
  • Examples: albuterol, levalbuterol
  • Used as needed for all severity levels 1

• Anticholinergics

  • Example: ipratropium bromide
  • Can be used as adjunctive therapy with SABAs for severe exacerbations 1

• Systemic Corticosteroids

  • Used for moderate to severe exacerbations
  • Short courses (5-10 days) to gain prompt control 1

Stepwise Approach to Asthma Management

Mild Intermittent Asthma

• No daily controller medication needed
• SABA as needed for symptom relief 1

Mild Persistent Asthma (Step 2)

• Preferred: Low-dose ICS
• Alternatives: Leukotriene modifier, cromolyn, nedocromil, or theophylline 1, 2

Moderate Persistent Asthma (Step 3)

• Preferred: Low-dose ICS plus LABA or medium-dose ICS
• Alternative: Low-dose ICS plus leukotriene modifier or theophylline 1, 2

Severe Persistent Asthma (Steps 4-6)

• Medium to high-dose ICS plus LABA
• Consider adding oral corticosteroids for step 6
• Consider omalizumab for patients ≥12 years with allergies 1

Monitoring and Adjusting Therapy

• If using SABA more than twice weekly, step up therapy 2
• If nighttime symptoms occur more than twice monthly, step up therapy 2
• Consider step-down therapy if asthma remains well-controlled for at least three months 2
• Monitor peak expiratory flow to guide therapy adjustments 1

Important Safety Considerations

• ICS may cause local side effects like oral candidiasis and dysphonia 3
• Higher doses of ICS may be associated with systemic effects including adrenal suppression, reduced bone mineral density, and growth effects in children 3
• LABAs should never be used as monotherapy due to increased risk of asthma-related death 1
• Regular monitoring of symptoms, lung function, and medication use is essential 2

Common Pitfalls to Avoid

• Overreliance on SABAs: If using more than one canister per month, daily controller therapy should be increased 1
• Underuse of ICS: Many patients underuse controller medications and overuse rescue medications
• Poor inhaler technique: Ensure proper inhaler technique through demonstration and regular assessment
• Lack of written asthma action plan: All patients should have a written plan for managing exacerbations 1
• Failure to address comorbidities: Conditions like allergic rhinitis, sinusitis, and GERD can worsen asthma control and should be treated 1

The evidence clearly demonstrates that inhaled corticosteroids are the cornerstone of asthma management, with additional medications added in a stepwise approach based on asthma severity and control.