The goal of asthma treatment is to reduce symptoms, improve lung function closer to normal, and reduce the risk of exacerbations. Asthma is managed in a step-wise approach depending on the severity of disease. Patients should be moved up to a higher step when they have poor symptom control and should be lowered a step once they are well-controlled for at least three months. Education on avoidance of triggers and having an asthma action plan are also mainstays of treatment. For patients with poorly controlled asthma despite being on high doses of inhaled corticosteroids and for those with allergy related asthma, biologics may be an appropriate next step.
Preferred: Short-acting inhaler as needed
Preferred: Low-dose inhaled steroid
Alternative: Cromolyn, leukotriene, modifying agent, or theophylline
Preferred: Low-dose inhaled steroid plus a long-acting beta agonist OR medium-dose inhaled steroid
Alternative: Low-dose inhaled steroid plus either leukotriene modifying agent or theophylline
Preferred: Medium-dose inhaled steroid plus a long-acting beta agonis
Alternative: Medium-dose inhaled steroid plus either a leukotriene modifying agent or theophylline
Preferred: High-dose inhaled steroid and long-acting beta agonist
Consider: Biologics for patients who have allergies
Preferred: High-dose inhaled steroids plus long-acting beta agonist plus oral steroids
Consider: Biologics for patients who have allergies
Short-Acting Beta Agonists (SABA): These medications are known as rescue inhalers and should be used during an asthma attack or before exercise, as directed. They work by relaxing the smooth muscle in the lungs that constricts and makes it difficult to breath during an asthma attack. They do not help to reduce the frequency of asthma attacks and should only be used as needed. If these medications need to be used more than twice per week, it may be a sign that your asthma is not well controlled, and another type of medication is needed. Common side effects are fast heartbeat or palpitations, headache, and tremor.
- Available short-acting beta agonists include albuterol and levalbuterol.
Anticholinergic Agents: These medications also work by relaxing the smooth muscle in the lungs that constricts during an asthma attack. Short acting agents such as ipratropium, can be used to treat symptoms of shortness of breath and wheezing, but longer acting medications such as tiotropium are used to prevent asthma attacks. Many of the medications in this class are approved to treat Chronic Obstructive Pulmonary Disease (COPD), another lung condition, but are not approved for treatment of asthma. Common side effects are dry mouth, urinary retention, and worsening of narrow-angle glaucoma.
- Available anticholinergic agents include ipratropium and tiotropium.
Inhaled Corticosteroids (ICS): These medications, also known as maintenance inhalers, are meant to be used daily to reduce the risk of asthma attacks and improve lung function. They work by reducing both inflammation and the body’s immune response to allergens. Unlike oral corticosteroids, these medications are inhaled directly into the lungs, and therefore they have a lower risk of systemic side effects. It is important to rinse your mouth with water and spit it out after each use of the inhaler to avoid the risk of an infection called thrush. Daily adherence to these medications is very important in order for them to be able to work the best. Common side effects are headache, thrush, nausea, sore throat, runny nose, and hoarseness.
- Available inhaled corticosteroids include beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone, mometasone, and triamcinolone.
Leukotriene Modifying Agents: These are medications that are taken orally to reduce the risk of having an asthma attack. They work by blocking the activity of a specific cell involved in the body’s immune response to allergens that can lead to airway swelling and smooth muscle constriction. Common side effects include cough, headache, sore throat, and runny nose.
- Available leukotriene modifying agents include montelukast, zafirlukast, and zileuton.
Long-Acting Beta Agonists (LABA): These medications work similarly to short-acting beta agonists in that they promote bronchodilation but provide a longer response. They should always be prescribed in combination with an inhaled corticosteroid when being used to treat asthma. Monotherapy with long-acting beta agonists may increase the risk of side effects, but when used with inhaled corticosteroids can help achieve better asthma control than with inhaled corticosteroids alone. Common side effects are headache, nasal congestion, sore throat, runny nose, and bronchitis.
- Available long-acting beta agonists include salmeterol, formoterol, and vilanterol.
Xanthine Derivatives: These medications work by relaxing smooth muscle in the airways and reducing inflammation. Common side effects are headache, insomnia, nausea, and vomiting.
- Available xanthine derivatives include theophylline.
Mast Cell Stabilizers: These medications works by binding to a particular cell involved in the immune system response to block the release of histamine, a chemical involved in allergic reactions. Common side effects are throat irritation, bad taste, cough, wheeze, and nausea.
- Available mast cell stabilizers include cromolyn.
Oral corticosteroids: This class of medications works similarly to inhaled corticosteroids in reducing inflammation and the body’s immune system response to allergens however, they are taken orally and therefore can affect the whole body, not just the lungs. For this reason, treatment with oral corticosteroids should be reserved for severe asthma and should be used for as short a time as possible to reduce the risk of side effects. Common side effects are fluid retention, alteration in glucose tolerance, high blood pressure, mood changes, increased appetite, and weight gain.
- Available oral corticosteroids include prednisone, methylprednisolone, dexamethasone, hydrocortisone, cortisone, and prednisolone.
Biologics: These medications are injected under the skin by a healthcare professional and are administered generally every two, four, or eight weeks. They are all antibodies that target specific cell types in the body’s immune system to block the inflammatory response that occurs in asthma. These types of medications are used in severe asthma that is not well controlled by inhaled corticosteroids or if patients have a particular type of asthma that is associated with allergies and a type of immune cell known as an eosinophil. Common side effects are fatigue, pain, and injection site reaction.
- Available biologics include omalizumab, reslizumab, benralizumab, mepolizumab, and dupilumab.
Overcoming Medication Challenges
It is important for you to know the benefits of your medications. Here at Magellan Rx, we understand your concerns and want to help you with any difficulties you may encounter. For additional information on how to overcome medication challenges, please click here: Overcoming Medication Challenges.