What are examples of medications used to treat asthma?

Asthma Medications: A Comprehensive Overview

Asthma medications are divided into two main categories: long-term controller medications (primarily inhaled corticosteroids) and quick-relief medications (short-acting beta-agonists), with inhaled corticosteroids being the most effective single therapy for persistent asthma at all severity levels. 1

Long-Term Controller Medications

Inhaled Corticosteroids (ICS) - First-Line Therapy

Inhaled corticosteroids are the most consistently effective long-term control medication for persistent asthma in both children and adults, superior to all other single long-term control medications including leukotriene receptor antagonists. 1 They work by reducing airway hyperresponsiveness, inhibiting inflammatory cell migration and activation, and blocking late-phase allergic reactions. 1

Common ICS medications include:

• Fluticasone propionate 1
• Beclomethasone 2
• Budesonide 1

ICS therapy reduces both impairment and risk of exacerbations, though it does not alter disease progression or underlying severity in children. 1 These medications are effective across all age groups and asthma severity levels. 3

Long-Acting Beta-Agonists (LABAs)

LABAs should NEVER be used as monotherapy for asthma - they must always be combined with inhaled corticosteroids due to FDA safety warnings regarding increased severe exacerbations and deaths when used alone. 1

Available LABAs include:

• Salmeterol (duration >12 hours) 1, 4
• Formoterol (duration >12 hours) 1

These medications are highly specific for β-adrenergic receptors, resulting in low rates of tremor and tachycardia. 1 For moderate to severe persistent asthma, adding a LABA to ICS therapy provides superior control compared to doubling the ICS dose alone. 5, 2

Combination ICS/LABA Products

Combination inhalers deliver both anti-inflammatory and bronchodilator therapy in a single device, improving adherence and asthma outcomes. 5

Available combinations:

• Fluticasone/salmeterol (Advair, Wixela Inhub) - available in 100/50,250/50, and 500/50 mcg strengths 1, 4, 5
• ICS-formoterol combinations 1, 6

The combination approach provides greater asthma control than increasing ICS dose alone while reducing exacerbation frequency and severity. 5

Leukotriene Modifiers

Leukotriene receptor antagonists are alternative (not preferred) therapy for mild persistent asthma when patients cannot or will not use inhaled corticosteroids. 1

Available agents:

• Montelukast (Singulair) - once daily dosing, approved for patients >1 year old 1
• Zafirlukast (Accolate) - twice daily dosing, approved for patients ≥7 years old 1
• Zileuton (Zyflo) - 5-lipoxygenase inhibitor requiring liver function monitoring 1

Note: The FDA issued a Boxed Warning for montelukast in March 2020 regarding neuropsychiatric adverse events. 1

These medications interfere with leukotriene mediator pathways released from mast cells, eosinophils, and basophils. 1 They offer ease of use and high compliance rates but are less effective than ICS therapy. 1

Mast Cell Stabilizers

Cromolyn sodium and nedocromil are alternative (not preferred) medications for mild persistent asthma. 1 They stabilize mast cells and interfere with chloride channel function. 1 These can also be used preventively before exercise or unavoidable allergen exposure. 1

Immunomodulators (Biologics)

Omalizumab (anti-IgE) is a monoclonal antibody indicated for patients ≥12 years with allergic asthma requiring step 5 or 6 care (severe persistent asthma) who have documented sensitivity to perennial allergens (dust mite, cockroach, cat, dog). 1 Clinicians must be prepared to identify and treat anaphylaxis when administering omalizumab. 1

Tezepelumab is recommended for patients >12 years with severe asthma uncontrolled despite high-dose ICS plus multiple controllers, with daily symptoms, frequent exacerbations requiring oral corticosteroids, and poor Asthma Control Test scores. 7

Theophylline

Sustained-release theophylline (target serum concentration 5-15 mcg/mL) is an alternative but not preferred option due to increased risk of adverse effects and need for monitoring. 1

Quick-Relief Medications

Short-Acting Beta-Agonists (SABAs)

All patients with asthma require a short-acting bronchodilator for acute symptom relief. 1 These are used as needed for symptoms, with intensity depending on severity - up to 3 treatments at 20-minute intervals. 1

Critical monitoring point: Use of SABA >2 days per week for symptom relief (not exercise prevention) indicates inadequate control and need to step up therapy. 1 Using more than one canister per month signals need for increased long-term control medication. 1

Oral Corticosteroids

For acute exacerbations:

• Children: 1-2 mg/kg/day for 3-10 days 1
• Adults: 40-60 mg/day in 1-2 divided doses for 5-10 days 1
• Tapering is not necessary 1

For severe persistent asthma (step 6 care): Long-term oral systemic corticosteroids may be required. 1

Stepwise Treatment Algorithm

Step 1 (Mild Intermittent)

• Preferred: SABA as needed only 1

Step 2 (Mild Persistent)

• Preferred: Low-dose ICS 1
• Alternative: Cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline 1

Step 3 (Moderate Persistent)

• Preferred: Low-dose ICS + LABA, OR medium-dose ICS 1
• Alternative: Low-dose ICS + leukotriene receptor antagonist or theophylline 1

Step 4

• Preferred: Medium-dose ICS + LABA 1
• Alternative: Medium-dose ICS + leukotriene receptor antagonist or theophylline 1

Step 5 (Severe Persistent)

• Preferred: High-dose ICS + LABA 1
• Consider adding biologics (omalizumab, tezepelumab) for allergic asthma 1, 7

Step 6

• High-dose ICS + LABA + oral systemic corticosteroids 1

Critical Safety Considerations

Never use LABAs as monotherapy - this has been associated with increased severe exacerbations and deaths. 1 Always combine with ICS therapy.

Antibiotics are only indicated if bacterial infection is present - they are not routine asthma treatment. 1

Sedation is contraindicated in acute asthma. 1

Monitor for local ICS effects: oral candidiasis (prevented by rinsing after use), dysphonia (may resolve by switching from dry powder to metered-dose inhaler with spacer), and cough. 1

Genetic considerations: Some ethnic populations, particularly Black patients, may have β-adrenergic receptor variations reducing LABA effectiveness, though recent research questions this. 1