What are the recommended asthma medications, including their dosing, indications, and contraindications?

Asthma Medications: Dosing, Indications, and Contraindications

Quick-Relief (Rescue) Medications

For acute bronchospasm, albuterol remains the first-line rescue medication across all age groups, but overuse signals inadequate controller therapy. 1

Short-Acting β-Agonists (SABAs)

Albuterol (Salbutamol)

• Nebulized dosing: Adults receive 2.5–5 mg every 20 minutes for three doses, then every 1–4 hours as needed; pediatric patients receive 5 mg (half dose for very young children) repeatable every 30 minutes if no improvement 1
• MDI dosing: Two puffs via large-volume spacer, repeatable 10–20 times if nebulizer unavailable 1
• Indication: First-line as-needed relief of acute bronchospasm in all age groups 1
• Critical caveat: Use of >1 inhaler canister per month signals the need to step up daily controller therapy 1

Terbutaline

• Dosing: Adults and children receive 10 mg via oxygen-driven nebulizer as alternative rescue bronchodilator 1
• Indication: Alternative to albuterol for acute bronchospasm 1

Anticholinergics

Ipratropium Bromide

• Adult dosing: 0.5 mg nebulized every 6 hours 1
• Pediatric dosing: 100 µg nebulized every 6 hours 1
• Indication: Adjunct to β-agonists for moderate-to-severe acute exacerbations; add if no improvement after 15–30 minutes of SABA therapy 1
• Administration: Combine with β-agonist in nebulizer for severe exacerbations 2

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Systemic Corticosteroids for Acute Exacerbations

Oral corticosteroids must be administered within 1 hour of presentation for all moderate-to-severe exacerbations, as delaying systemic steroids is a documented cause of preventable asthma deaths. 1, 3

Oral Corticosteroids (Preferred Route)

Prednisone/Prednisolone

• Adult dosing: 40–60 mg once daily (or divided) for 5–10 days without taper; severe attacks may require 40–80 mg daily until peak expiratory flow (PEF) reaches ≥70% of predicted 1, 3
• Pediatric dosing: 1–2 mg/kg/day (maximum 60 mg) divided into two doses for 3–10 days without taper 1, 3
• Indication: All moderate-to-severe exacerbations not responding to initial bronchodilator therapy; should be given within 1 hour of emergency department arrival 1, 3
• Duration: Continue until PEF ≥70% of predicted or personal best 3
• Tapering: No taper needed for courses ≤10 days, especially if patient is on inhaled corticosteroids 1, 3
• Route preference: Oral administration is equally effective as IV when gastrointestinal absorption is intact and is strongly preferred as less invasive 1, 3

Intravenous Corticosteroids (Reserved for Specific Situations)

Hydrocortisone

• Adult dosing: 200 mg IV bolus, then 200 mg every 6 hours 1, 3
• Pediatric dosing: 4 mg/kg IV initial dose 1
• Indication: Patients who are vomiting, severely ill, or unable to tolerate oral medication 1, 3

Methylprednisolone

• Adult dosing: 40–80 mg/day IV in divided doses (or single 125 mg dose, range 40–250 mg) until PEF ≥70% predicted 1, 3
• Pediatric dosing: 0.25–2 mg/kg/day (maximum 60 mg) divided 1
• Indication: Alternative IV corticosteroid when hydrocortisone is not preferred 1

Critical pitfall: Do not delay systemic corticosteroids in moderate-to-severe exacerbations; underuse is a documented cause of preventable asthma deaths 1. The minimum effective adult dose is 30–60 mg daily—do not underdose 1.

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Long-Term Controller Therapy (Stepwise Approach)

For patients with persistent asthma, daily anti-inflammatory treatment with inhaled corticosteroids is the cornerstone of therapy regardless of age group. 2

Step 1: Mild Intermittent Asthma

• Treatment: No daily controller; short-acting β-agonist (SABA) PRN only 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroid (ICS) 1
• Alternatives: Cromolyn, leukotriene receptor antagonist, nedocromil (except <5 years), or sustained-release theophylline targeting serum 5–15 µg/mL 1

Step 3: Moderate Persistent Asthma

• Preferred: Low-to-medium-dose ICS + long-acting β-agonist (LABA) 1
• Alternative for children <5 years: Medium-dose ICS alone is acceptable 1
• Critical warning: LABAs must only be used in combination with ICS therapy; the FDA has issued a black-box warning against LABA monotherapy for long-term control of asthma 2

Step 4: Severe Persistent Asthma

• Treatment: High-dose ICS + LABA; add oral corticosteroid if control remains inadequate 1

Inhaled Corticosteroids

Examples: Budesonide, beclomethasone, ciclesonide, flunisolide, fluticasone, mometasone, triamcinolone 2

• Mechanism: Anti-inflammatory, targeting airway inflammation that is a key component of asthma disease process 2
• Administration: Inhaled once or twice daily 2
• Indication: Daily anti-inflammatory treatment for all patients with persistent asthma 2, 1

Long-Acting β-Agonists (LABAs)

Examples: Salmeterol, formoterol 2

• Mechanism: Bronchodilator with complementary mechanism to ICS (targeting bronchoconstriction of airway smooth muscle) 2
• Administration: Inhaled twice daily 2
• Indication: Long-term control agents used in conjunction with ICS therapy at step 3 or higher 2
• Contraindication: Never use as monotherapy—FDA black-box warning 2

Combination ICS/LABA Products

Examples: Salmeterol/fluticasone, formoterol/budesonide 2

• Mechanism: Combination anti-inflammatory/bronchodilator 2
• Administration: Inhaled twice daily 2
• Indication: Moderate-to-severe persistent asthma requiring step 3 or higher therapy 2

Leukotriene Modifiers

Examples: Montelukast, zileuton 2

• Mechanism: Block the leukotriene pathway (proinflammatory lipid mediators that promote airway smooth muscle contraction); show both modest anti-inflammatory and bronchodilating activity 2
• Administration: Oral (once daily for montelukast, twice daily for zileuton) 2
• Indication: Alternative controller therapy at step 2; add-on therapy at higher steps 2, 1

Mast Cell Stabilizers

Examples: Cromolyn, nedocromil 2

• Mechanism: Anti-inflammatory (stabilizes mast cells and interferes with chloride channel function) 2
• Administration: Inhaled 4 times daily 2
• Indication: Alternative controller therapy at step 2 2

Methylxanthines

Theophylline

• Mechanism: Bronchodilator; may have mild anti-inflammatory effects 2
• Administration: Oral (liquid, sustained-release tablets, and capsules) 2
• Target serum level: 5–15 µg/mL 1
• Indication: Alternative controller therapy at step 2 2, 1

Immunomodulators

Omalizumab (Anti-IgE)

• Mechanism: Recombinant humanized monoclonal antibody that specifically binds to free IgE, blocking the allergic cascade by preventing IgE binding to effector cells such as mast cells and basophils 2
• Administration: Subcutaneous injection once every 2 or 4 weeks 2
• Indication: Patients aged 12 years or older at steps 5 and 6 (high-dose ICS plus LABA) who have IgE-mediated allergic asthma with clinical history of allergies and evidence of elevated IgE 2

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Aminophylline (Reserved for Life-Threatening Asthma)

Aminophylline should only be used for life-threatening features or failure to improve with nebulized β-agonists and systemic corticosteroids. 1

• Loading dose: 5 mg/kg IV over 20 minutes (omit if patient is already on oral theophylline to avoid toxicity) 1
• Maintenance infusion: 0.5–0.7 mg/kg/hour with continuous serum theophylline monitoring 1
• Indication: Only for life-threatening features (PEF <33%, silent chest, confusion, exhaustion) or failure to improve with standard therapy 1
• Caution: Do not give bolus aminophylline if patient is already taking theophyllines 2

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Emerging Rescue Therapy: Albuterol-Budesonide Combination

Recent evidence supports the use of fixed-dose combination albuterol-budesonide as rescue therapy to reduce exacerbation risk in moderate-to-severe asthma. 4

• Dosing: 180 µg albuterol + 160 µg budesonide (two actuations of 90/80 µg) as needed 4
• Indication: FDA-approved for as-needed treatment or prevention of bronchoconstriction and reducing exacerbation risk in patients aged ≥18 years with moderate-to-severe asthma 5
• Evidence: Reduces risk of severe asthma exacerbation by 26% compared to albuterol alone in patients on maintenance ICS therapy 4
• Not indicated: For maintenance therapy or single maintenance and reliever therapy (SMART) 5

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Critical Clinical Pitfalls to Avoid

• Do not delay systemic corticosteroids in moderate-to-severe exacerbations; underuse is a documented cause of preventable asthma deaths 1
• Avoid under-dosing oral steroids; the minimum effective adult dose is 30–60 mg daily 1
• Do not taper short courses (<7–10 days) of corticosteroids; tapering is unnecessary and may lead to under-dosing 1, 3
• Monitor SABA overuse as a marker of poor control; >1 inhaler canister per month warrants escalation of controller therapy 1
• Oral corticosteroids are equally effective as IV when gastrointestinal absorption is intact; IV administration is unnecessarily invasive 1, 3
• Never use LABAs as monotherapy—FDA black-box warning against use without concurrent ICS 2
• Do not introduce sedating antihistamines (e.g., hydroxyzine) during acute exacerbations; focus must remain on bronchodilators and systemic corticosteroids 6