Different classes of medicines are useful in the treatment of asthma. The NAEPP’s asthma classification helps define the severity of a person’s asthma and assists in guiding therapy. Notice that for each asthma classification, the NAEPP makes specific suggestions about the best type of medicine to use for treating that specific level of asthma.
Asthma medicines are best prescribed in a stepwise approach. The physician initiates treatment with one or two types of medicine, based on the patient’s initial degree of asthma severity and then adds or reduces medication based on the patient’s symptom control, lung function, and overall state of well-being. A person with intermittent asthma might be instructed to use a short-acting β2 inhaler as needed for symptom relief. With the onset of winter and colder temperatures, that individual’s symptoms may start to become more prominent and increase.
The inhaled, short-acting β2 medicine that formerly kept asthma symptoms under control might be required several times daily. No longer intermittent, this patient’s asthma has “moved up” a classification to become mild persistent asthma. Just as the classification has moved up, the treatment is stepped up or intensified. For this patient, an additional, second medication with anti-inflammatory properties, such as an inhaled steroid in low doses, would be a good choice .
Once good asthma control is achieved with the combination of an inhaled anti-inflammatory and a β2 bronchodilator, and after the improvement is sustained for at least three months, it would then be appropriate to consider a step down, especially if the stimulus to stepped-up asthma has resolved (such as the end of cold winter weather).
Asthma Medication Facts
Short-Acting β2 Agonist (SABA) bronchodilators: albuterol (called salbutamol outside the United States), levalbuterol, pirbuterol are as needed, quick-relief asthma medicines.
- All persons with asthma need a prescription for an inhaled SABA.
- Inhaled SABAs are prescribed for fast symptom relief, and used only when and as needed.
- Inhaled SABAs are the most effective therapy for rapid reversal of symptoms of bronchoconstriction.
- Inhaled SABAs have an onset of action of 5 minutes or less.
- Inhaled SABAs have a peak effect 30 to 60 minutes after inhalation.
- Inhaled SABAs’ effects on bronchoconstriction last for 4 to 6 hours.
- When inhaling two puffs of a SABA, you should wait 10–15 seconds between puffs.
Inhaled Corticosteroids (ICS)
- Any person with asthma that is persistent (mild, moderate, or severe persistent) should use an ICS every day. The dose will vary depending on the extent of asthma.
- ICSs are the cornerstone of preventive therapy in all forms of persistent asthma.
- ICSs reduce and suppress inflammation in the airways and so prevent asthma symptoms.
- ICSs are daily-use controller medicines.
- Daily ICS use results in improved asthma outcomes and improved quality of life.
- Many physicians (and therefore their patients) do not follow national guidelines such as the NAEPP for ICS prescribing in asthma.
- Long-acting β2 agonist bronchodilators should never be used without simultaneous anti-inflammatory medication, such as ICS.
Asthma treatment must take into account the often fluid and changeable character of asthma itself. A useful and practical way of classifying asthma medicines is by their method of action. In such a schema, the two major categories of medicine used in asthma treatment are quick-relief, fast-acting medicines and long-term control medicines. Quick-relief asthma medicines have a prompt onset of action and act rapidly to relieve airway narrowing (bronchoconstriction).
You may know them as “reliever” or “rescue” medications. They include the short-acting β2 agonist bronchodilators, or SABA, inhaled anticholinergics, and oral (pill or liquid) corticosteroid bursts. The long-term control asthma medicines must be taken daily to achieve control of asthma, and then to maintain that level of control. They are referred to interchangeably as “long-term preventive,” “controller,” or “maintenance” medications. They include the inhaled corticosteroids , inhaled forms of cromolyn and nedocromil, leukotriene modifiers , long-acting β2 agonist bronchodilators, or LABA , theophylline, and anti-IgE immunomodulator medication.
Persons with persistent asthma (mild, moderate, or severe persistent asthma) require treatment with medicine from each of the two broad classes of asthma medication, using both quick-relief medication and long-term control medicines for optimal asthma control. The actual medication and dosages are, of course, best selected by the treating physician. Individuals whose asthma is intermittent, according to the NAEPP classification and criteria, will
typically be prescribed a quick-relief medicine alone, such as a short-acting β2 agonist bronchodilator (SABA) inhaled as needed for symptom relief.
Most asthma medicines are inhaled (Table 37). The inhaled route is preferred because it delivers the medicine directly into the breathing passages. Why take a pill form of a medicine that leads to measurable drug levels in the entire body when you can deposit effective medicine exactly where it’s needed for quick symptom relief?
In addition, side effects, if any, are minimal. Short-acting β2 agents (SABA) like albuterol, levalbuterol, and pirbuterol in inhaled form are all examples of ideal, quick-relief medicines that relax smooth muscle and bronchodilate the breathing passages (Table 34). They are the therapy of choice for the relief of acute symptoms and for pre-exercise treatment in persons with EIB. Quick-relief or “rescue”inhalers are thus usually prescribed for use when needed.
The onset of action is rapid, and the beneficial effects last between 4 and 6 hours. You should keep your quick-relief inhaler handy during the day. Keep it in a briefcase, pocket, purse, or gym bag. Like your house key, your quick-relief inhaler should accompany you wherever you go.
Asthma Medicines Delivered via Inhalers
Short-Acting, Quick-Relief β2-Agonist Bronchodilators (SABA)
ProAir HFA (albuterol sulfate)
Proventil HFA (albuterol sulfate)
ReliOn Ventolin HFA (albuterol sulfate)
Ventolin HFA (albuterol sulfate)
Xopenex HFA (levalbuterol HCl)
Maxair Autohaler (pirbuterol acetate)
Daily Use Anti-Inflammatory Corticosteroids
Aerobid (flunisolide)
Aerospan HFA (flunisolide hemihydrate)
Alvesco HFA (ciclesonide)
Asmanex (mometasone furoate)
Azmacort (triamcinolone acetonide)
Flovent HFA (fluticasone propionate)
Pulmicort Flexhaler (budesonide)
Qvar (beclomethasone dipropionate)
Anti-Inflammatory and Anti-Allergy
Intal MDI (cromolyn sodium)—no longer manufactured as MDI after 2009
Tilade MDI (nedocromil sodium)—no longer manufactured as MDI after 2008
Combination Products
Advair (fluticasone propionate & salmeterol xinafoate)
Symbicort (budesonide & formoterol fumarate)
Long-Acting Daily Use β2-Agonist Bronchodilators (LABA)
Foradil (formoterol fumarate)
Serevent (salmeterol xinafoate)
LABA should not be taken alone, but simultaneously with inhaled corticosteroids
Daily long-term asthma control medicines are used in addition to quick-relief medicine for treatment of the persistent forms of asthma: mild persistent, moderate persistent, and severe persistent. Controller medicines include both inhaled and oral preparations. The NAEPP recommends inhaled corticosteroids as first-line inhaled anti-inflammatory treatment and advocates their use beginning with mild persistent asthma (see Table 33).
The leukotriene-modifier class of controller-asthma medicine is a newer type of controller medication (see Table 38). The group includes montelukast and zafirlukast, which are of the LTRA (leukotriene receptor antagonist) sub-class as well as a third drug, zileuton, which acts by a different mechanism (as a lipoxygenase pathway inhibitor). The two LTRAs are FDA approved for young children (montelukast for children over the age of 1 year, and zafirlukast for youngsters aged 7 years and older) in addition to adolescents and adults.
Since montelukast requires once-a-day dosing and can be taken either with a meal or on an empty stomach, it is more convenient for patients than zafirlukast, which is a twice-a-day medication and is best taken on an empty stomach. The leukotriene modifiers appear to be most useful in persons with a dual diagnosis of asthma and allergy, especially if allergic rhinitis and asthma co-exist. Leukotriene modifiers are also effective in exercise-induced bronchospasm (EIB), which is described in Question 36.
Long-term control medication must be taken as pre-scribed, day in and day out, even if symptoms are quiescent. Most controller medications can be left at home and are taken once or twice daily, depending on the medicine and the prescription.
Several years ago, I was completing my pulmonary fellowship at Bellevue Hospital in New York City. An elderly lady with complicated asthma was assigned to my clinic for her care. At first, she had difficulty understanding how and when to use her inhalers. We reviewed the different medicines, which ones were as-needed, quick-relief and which ones were day-in and day-out controllers for maintenance.
After a few moments, a broad, triumphant grin spread across my patient’s face. “I got it!” she exclaimed. A minute later, she elaborated, “The white inhaler is like my husband—he’s always there, morning and night; but, the yellow one is like my boyfriend—he comes around only when I need him!” From that day on, there was no more confusion about those inhalers!