What are the best maintenance and reliever medications for asthma?

Best Maintenance and Reliever Medications for Asthma

For asthma management, inhaled corticosteroids (ICS) are the cornerstone of maintenance therapy, while short-acting beta-agonists (SABAs) are the primary reliever medications, with combination ICS-LABA therapy being the preferred treatment for moderate to severe persistent asthma. 1

Maintenance Medications

First-Line Maintenance Therapy

• Inhaled Corticosteroids (ICS): The foundation of asthma control
  • Options include fluticasone propionate, beclomethasone, budesonide, and mometasone 1
  • Effective at reducing airway inflammation, preventing exacerbations, and improving lung function 2
  • Standard daily dose of fluticasone propionate 200-250 μg or equivalent achieves 80-90% of maximum therapeutic benefit 3

Step-Up Maintenance Therapy

• ICS + Long-Acting Beta-Agonists (LABA): Preferred combination for moderate to severe persistent asthma

  • Examples: fluticasone/salmeterol, budesonide/formoterol 1
  • Provides superior control compared to doubling ICS dose alone 4
  • LABAs should never be used as monotherapy due to increased risk of asthma-related death 1

• Leukotriene Receptor Antagonists (LTRAs):

  • Montelukast, zafirlukast
  • Alternative (not preferred) therapy for mild persistent asthma 2
  • Can be used as adjunctive therapy with ICS 2
  • Less effective than adding LABA to ICS 2

• Methylxanthines (Theophylline):

  • Alternative (not preferred) therapy for mild persistent asthma 2
  • Can be used as adjunctive therapy with ICS 2
  • Requires serum level monitoring 2

• Biologics (for severe asthma):

  • Omalizumab for patients with severe persistent asthma and allergen sensitivity 2
  • Clinicians should be prepared to treat potential anaphylaxis 2

Reliever Medications

• Short-Acting Beta-Agonists (SABAs):

  • Albuterol, levalbuterol, pirbuterol 2
  • First-line treatment for acute symptom relief 2
  • Also used for prevention of exercise-induced bronchoconstriction 2
  • Increasing use (>2 days/week) indicates poor control and need for controller therapy adjustment 2

• Anticholinergics:

  • Ipratropium bromide provides additive benefit to SABA in moderate/severe exacerbations 2
  • Alternative for patients who cannot tolerate SABAs 2

• Systemic Corticosteroids:

  • Used for moderate to severe exacerbations 2
  • Added to SABA to speed recovery and prevent recurrence 2

Stepwise Treatment Approach

1. Step 1 (Mild Intermittent): As-needed SABA or as-needed low-dose ICS-formoterol 1, 5

2. Step 2 (Mild Persistent): Daily low-dose ICS 2, 1

   • Alternative: LTRA, cromoglycate, nedocromil, or theophylline 2

3. Step 3 (Moderate Persistent): Low-dose ICS + LABA 2, 1

   • Alternative: Medium-dose ICS 2

4. Step 4 (Moderate-Severe Persistent): Medium-dose ICS + LABA 1

5. Step 5 (Severe Persistent): High-dose ICS + LABA 2, 1

   • Consider adding oral corticosteroids if needed 2

Important Clinical Considerations

• Monitoring: Regular assessment of symptom control, lung function, and medication adherence is essential 1

• Stepping Down: Consider stepping down therapy after 3 months of good control 1

• Combination Inhalers: May improve adherence compared to separate inhalers 6

• As-Needed ICS Strategies: For mild asthma, using ICS whenever SABA is used can reduce exacerbation risk 5

• Safety Concerns:

  • Rinse mouth after ICS use to prevent oral candidiasis 1
  • Monitor for potential steroid side effects with long-term use 1
  • Never use LABAs alone for asthma management 1

• Referral: Consider specialist referral for patients with uncontrolled symptoms despite Step 3 therapy, ≥2 exacerbations requiring oral corticosteroids in the past year, or requiring Step 4 care or higher 1

By following this evidence-based approach to asthma management, clinicians can effectively control symptoms, prevent exacerbations, and improve patients' quality of life.