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What is the treatment for asthma?
As per widely used guidelines, the treatment goals for asthma are to:
- adequately control symptoms,
- minimize the risk of future exacerbations,
- maintain normal lung function,
- maintain normal activity levels, and
- use the least amount of medication possible with the least amount of potential side effects.
Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents available for the chronic treatment of asthma and are first-line therapy per most asthma guidelines. It is well recognized that ICS are very effective in decreasing the risk of asthma exacerbations. Furthermore, the combination of a long-acting bronchodilator (LABA) and an ICS has a significant additional beneficial effect on improving asthma control.
The most commonly used asthma medications include the following:
- Short-acting bronchodilators (albuterol [Proventil, Ventolin, ProAir, Maxair, Xopenex]) provide quick relief and can be used in conjunction for exercise-induced symptoms.
- Inhaled steroids (budesonide [Pulmicort Turbuhaler, Pulmicort Respules], fluticasone [Flonase, Veramyst], beclomethasone [Vanceril, Beconase AQ, QNASL, Quvar], mometasone [Nasonex], ciclesonide [Alvesco]) are first-line anti-inflammatory therapy.
- Long-acting bronchodilators (salmeterol [Serevent], formoterol [Foradil]) can be added to ICS as additive therapy. LABAs should never be used alone for the treatment of asthma.
- Leukotriene modifiers (montelukast [Singulair], zafirlukast [Accolate]) can also serve as anti-inflammatory agents.
- Anticholinergic agents (ipratropium [Atrovent, Atrovent HFA], tiotropium [Spiriva]) can help decrease sputum production.
- Anti-IgE treatment (omalizumab [Xolair]) can be used in allergic asthma.
- Chromones (cromolyn [Intal, Opticrom, Gastrocrom], nedocromil [Alocril]) stabilize mast cells (allergic cells) but are rarely used in clinical practice.
- Theophylline (Respbid, Slo-Bid, Theo-24) also helps with bronchodilation (opening the airways) but again is rarely used in clinical practice due to an unfavorable side-effect profile.
- Systemic steroids (prednisone [Deltasone, Liquid Pred], prednisolone [Flo-Pred, Pediapred, Orapred, Orapred ODT], methylprednisolone [Medrol, Depo-Medrol, Solu-Medrol], dexamethasone [DexPak]) are potent anti-inflammatory agents that are routinely used to treat asthma exacerbations but pose numerous unwanted side effects if used repeatedly or chronically.
- Numerous other monoclonal antibodies are currently being studied but none are currently commercially available for routine asthma therapy.
There is often concern about potential long-term side effects of inhaled corticosteroids. Numerous studies have repeatedly shown that even long-term use of inhaled corticosteroids has very few if any sustained, clinically significant side effects, including changes in bone health, growth, or weight. However, the goal always remains to treat all individuals with the least amount of medication that is effective. Patients with asthma should be routinely reassessed for any appropriate changes to their medical regimen.
Asthma medications can be administered via inhalers either with or without an AeroChamber or nebulized solution. It is important to note that if an individual has proper technique with an inhaler, the amount of medication deposited in the lungs is no different than that when using a nebulized solution. When prescribing asthma medications, it is essential to provide the appropriate teaching on proper delivery technique.
Smoking cessation and/or minimizing exposure to secondhand smoke are critical when treating asthma. Treating concurrent conditions such as allergic rhinitis and gastroesophageal reflux disease (GERD) may also improve asthma control. Vaccinations such as the annual influenza vaccination are also indicated.
Although the vast majority of individuals with asthma are treated as outpatients, treatment of severe exacerbations can require management in the emergency department or inpatient hospitalization. These individuals typically require use of supplemental oxygen, early administration of systemic steroids, and frequent or even continuous administration of bronchodilators via a nebulized solution. Individuals at high risk for poor asthma outcomes are referred to a specialist (pulmonologist or allergist). The following factors should prompt consideration or referral:
- History of ICU admission or multiple hospitalizations for asthma
- History of multiple visits to the emergency department for asthma
- History of frequent use of systemic steroids for asthma
- Ongoing symptoms despite the use of appropriate medications
- Significant allergies contributing to poorly controlled asthma