What are the specific controller medications for asthma?
The first-line controller medications for asthma based on the Expert Panel Report (EPR-3) asthma guidelines from the National Heart, Blood, and Lung Institute (NHLBI) are inhaled corticosteroids. These medications are delivered either through inhaler devices or a nebulizer and help to control inflammation in the lungs due to asthma, thus improving symptoms and decreasing the risk of exacerbations. Inhaled corticosteroids by both generic and brand names include fluticasone (Flovent and Arnuity Ellipta), budesonide (Pulmicort), beclomethasone (Qvar), mometasone (Asmanex), and ciclesonide (Alvesco).
Combination controller medications exist for patients whose asthma symptoms are not well controlled on inhaled corticosteroids alone. These medications have a long-acting beta-agonist (formoterol, salmeterol, or vilanterol, which are medications that helps to open the airways [bronchodilate]), in addition to the inhaled corticosteroids. The combination controller medications include fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort), mometasone/formoterol (Dulera), and fluticasone/vilanterol (Breo). These medications are available for delivery by inhaler.
A class of oral medications for asthma is the leukotriene modifiers, which act on an immune pathway in the body (the leukotriene pathway) that is responsible for inflammation. This group of medications includes montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). These medications may be used alone in milder asthma but are often used along with inhaled corticosteroids in moderate to severe asthma.
There is a different type of inhaled medication called tiotropium (Spiriva) that may be used for asthma patients, usually together with inhaled corticosteroids. This medication may be indicated for patients who need a combination therapy but who are unable to tolerate the long-acting beta-agonists. This medication also may be appropriate for patients who have a history of asthma but who also have a history of smoking-related lung disease (chronic obstructive pulmonary disease). Tiotropium also may help to further improve symptoms in patients whose asthma is not well controlled on a combination inhaled corticosteroid/long-acting beta-agonist medication.
Another oral medication for asthma is called theophylline (Respbid, Slo-Bid, Theo-24). This is an older asthma medication that is not used as frequently today as in the past. This medication acts to open the airways (bronchodilate) and also improves inflammation in the lung due to immune cells activated in asthma. Theophylline is usually used in combination with other asthma medications. Its use is often limited by potential side effects that are not a concern with other asthma medications.
Cromolyn is an asthma medication that is only available in the United States for delivery via a nebulizer. Cromolyn is suggested as an alternative medication to inhaled corticosteroids for asthma control, usually in mild asthma. It is not a commonly used asthma medication.
There is also an injectable medication approved for allergic asthma, called omalizumab (Xolair) or anti-IgE therapy. This medication binds to the antibody type responsible for allergic reactions (immunoglobulin E or IgE) in the bloodstream and is indicated for severe, allergic asthma not controlled with any of the other available asthma medications. This medication must always be administered in a health-care setting.
Recently, two medications have been approved that bind to a chemical messenger in the body, called interleukin 5 (IL-5). Mepolizumab (Nucala) is administered subcutaneously, and reslizumab (Cinqair) is administered intravenously. IL-5 promotes activation and development of eosinophils, a type of white blood cell that is known to contribute to asthma in certain patients. These medications are indicated in patients with asthma not controlled by first line medications who also have an elevated eosinophil count in their blood.
Oral steroids, such as prednisone (Deltasone, Liquid Pred), prednisolone (Flo-Pred, Pediapred, Orapred, Orapred ODT), methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol), and dexamethasone (DexPak), are often used during asthma flares to provide prompt relief for asthmatic patients. Although very effective, these medications have many side effects and are only used when absolutely necessary. Some patients with severe asthma, however, may require oral steroids frequently or even on a daily basis.
A complete list of commonly used asthma medications is as follows:
- Short-acting bronchodilators provide quick relief and can be used in conjunction for exercise-induced symptoms. Albuterol (Proventil, Ventolin, ProAir, Maxair, Xopenex) is a short-acting bronchodilator.
- Inhaled steroids are first-line anti-inflammatory therapy. Examples of these medications include budesonide (Pulmicort), fluticasone (Flovent), beclomethasone (Qvar), mometasone (Asmanex), and ciclesonide (Alvesco).
- Long-acting bronchodilators can be added to inhaled corticosteroids. These should never be used alone for the treatment of asthma. Salmeterol and formoterol are in this class.
- Leukotriene modifiers can also serve as anti-inflammatory agents. These medications include montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo).
- Anticholinergic agents can help decrease sputum production. Examples of these medications include ipratropium (Atrovent) and tiotropium (Spiriva).
- Anti-IgE can be used in moderate to severe allergic asthma. Omalizumab (Xolair) is an anti-IgE medication.
- Anti-IL-5 agents can be used in moderate to severe asthma with elevated eosinophils. These include mepolizumab (Nucala) and reslizumab (Cinqair).
- Chromones stabilize mast cells (allergic cells) but are rarely used in clinical practice. Cromolyn and nedocromil (Alocril) are in this drug class.
- 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.
- Oral steroids are potent anti-inflammatory agents that are routinely used to treat asthma exacerbations but pose numerous unwanted side effects if used repeatedly or chronically. Prednisone (Deltasone, Liquid Pred), prednisolone (Flo-Pred, Pediapred, Orapred, Orapred ODT), methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol), and dexamethasone (DexPak) are medications in this class.
Numerous new medications are being studied, but none are currently commercially available for routine therapy of asthma.