From the Guidelines
Maintenance therapies for asthma include inhaled corticosteroids (ICS), long-acting beta2-agonists (LABAs), leukotriene modifiers, cromolyn sodium, and immunomodulators. The most effective long-term control medications are those that attenuate the underlying inflammation characteristic of asthma, with ICS being the most consistently effective at all steps of care for persistent asthma 1.
Long-term Control Medications
- Inhaled Corticosteroids (ICS): reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late-phase reaction to allergen 1.
- Long-acting beta2-agonists (LABAs): used in combination with ICS for long-term control and prevention of symptoms in moderate or severe persistent asthma, and are the preferred therapy to combine with ICS in youths 12 years of age and adults 1.
- Leukotriene modifiers: alternative, but not preferred, therapy for the treatment of patients who require step 2 care, and can be used as adjunctive therapy with ICS 1.
- Cromolyn sodium and nedocromil: stabilize mast cells and interfere with chloride channel function, used as alternative, but not preferred, medication for patients requiring step 2 care 1.
- Immunomodulators: such as omalizumab, used as adjunctive therapy for patients 12 years of age who have sensitivity to relevant allergens and who require step 5 or 6 care 1.
Combination Therapy
Combination therapy with ICS and LABAs is the most effective and safe in preventing severe exacerbations of asthma, with a rate ratio of 0.44 (95% CrI 0.29 to 0.66) compared to low dose inhaled corticosteroids 1.
Step-up and Step-down Therapy
If adherence and environment control measures are adequate, then step up 1 step (if not well controlled) or 2 steps (if very poorly controlled), and consider a step down in therapy once asthma is well controlled for at least 3 months 1.
Monitoring and Follow-up
Regular follow-up contact is essential to maintain control of asthma, with patient contact scheduled at 1-month to 6-month intervals, depending on the level or duration of asthma control and the level of treatment required 1.
From the Research
Maintenance Therapies for Asthma
The following are some of the maintenance therapies for asthma:
- Inhaled corticosteroids (ICSs) are recognized as the cornerstone of asthma therapy 2
- Leukotriene receptor antagonists (LTRAs) are also used as initial maintenance therapy in patients whose asthma is uncontrolled by bronchodilators alone 2
- Combination therapy with ICSs and a long-acting beta2-agonist as initial maintenance therapy if the disease is of sufficient severity 2
- Budesonide/formoterol maintenance and reliever therapy (Symbicort SMART) has been approved for adults in the European Union 3
- Single-inhaler combination therapy for maintenance and relief of asthma, such as salmeterol/fluticasone propionate (Seretide or Advair) or budesonide/formoterol (Symbicort) 4
Comparison of Maintenance Therapies
Studies have compared the effectiveness of different maintenance therapies for asthma, including:
- ICSs versus LTRAs: ICSs are more effective than LTRAs as initial maintenance therapy 2
- Budesonide/formoterol versus salmeterol/fluticasone: budesonide/formoterol maintenance and reliever therapy is superior to salmeterol/fluticasone plus SABA in reducing severe exacerbations and maintaining daily asthma control at a lower drug load 3
- Single-inhaler therapy versus combination inhalers: single-inhaler therapy with budesonide/formoterol reduces the number of people having asthma exacerbations requiring oral steroids and the number requiring hospitalisation or an ER visit compared with fixed-dose combination inhalers 5
Key Findings
Key findings from the studies include:
- ICSs are the most effective anti-inflammatory medication currently available for the treatment of persistent asthma 2
- Budesonide/formoterol maintenance and reliever therapy is a safe and simplified approach to asthma management, using a single inhaler, which reduces severe exacerbations and maintains similar daily asthma control at a lower drug load compared with the traditional strategy of ICS/LABA plus SABA 3
- Single-inhaler therapy with budesonide/formoterol reduces the number of people having asthma exacerbations requiring oral steroids and the number requiring hospitalisation or an ER visit compared with fixed-dose combination inhalers 5