| Treatment: Long-term control drugs |
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The main goal of most control drugs is to prevent symptoms from occurring in the first place. In general, anyone with persistent asthma -- whether mild, moderate, or severe -- should take a control drug every day. (Read more about children under age 5.)
Beyond this, the National Asthma Education and Prevention Program recommends that long-term control therapy should be considered in any infant or young child who has had more than three episodes of wheezing in the last year that lasted more than 1 day and affected sleep. They should also be given long-term control therapy if they are at risk for developing asthma. Children are at risk for asthma if they have a parent with asthma or eczema, or two of the following:
- Nasal allergies
- Wheezing apart from colds
- Evidence of allergies on a complete blood count test
This approach may prevent or delay the child developing asthma.
Some people who already have asthma use control drugs only during times when they are likely to be exposed to one of their asthma triggers, such as a particular season or when staying at a pet owner's house.
The following are the main drugs in this category.
Inhaled steroids
Steroids (also called corticosteroids) taken with an inhaler are very effective for long-term control when taken daily. They are generally a doctor's first choice for daily medication to treat persistent asthma at all levels of severity. For moderate-to-severe asthma, they may be even more effective when combined with long-acting beta agonists. (See combination therapy, below.) Steroids work by reducing inflammation in the airways. Steroids are generally inhaled using a metered dose inhaler (MDI) device or dry powder inhaler (DPI).
Pulmicort Respules is a drug approved for children 12 months - 8 years of age. This medicine is administered using a nebulizer, and therefore may be suitable for those who can't easily manipulate inhalers and spacers. Steroids are also available as pills, liquids, and other forms, but these are generally used in special cases, such as initial treatment to bring asthma under control or severe persistent asthma that has not been brought under control by other drug treatments.
Examples of other steroids include mometasone (Asmanex), triamcinolone (Azmacort), fluticasone (Flovent), and beclomethasone (Qvar). Flovent HFA and Qvar are steroids using an environmentally friendly propellant (non-CFC). Asmanex Twisthaler and Flovent Diskus are inhalation-driven devices that do not use a propellant, thus eliminating the need for hand-breath coordination.
Other long-term control drugs
Other drugs may be prescribed for everyday use to control asthma. By themselves, none has been demonstrated to be as effective as inhaled steroids. These other options include:
- Long-acting beta-agonists -- These help control moderate-to-severe asthma, prevent nighttime symptoms, and prevent exercise-induced attacks. The drugs work by relaxing the muscles of your bronchial tubes and are effective for 12 or more hours after a single dose. They include salmeterol (Serevent) and formoterol (Foradil). Formoterol is also avialable as a nebulized solution. IMPORTANT NOTE: These drugs are NOT formulated the same as "short-acting" beta-agonists, and should not be used for quick relief of symptoms. They are only for preventing symptoms from occurring in the first place. Note: On November 18, 2005, the U.S. Food and Drug Administration (FDA) notified manufacturers of Advair Diskus, Foradil Aerolizer, and Serevent Diskus to update their existing product labels with new warnings and later approved new safety labelling and Medication Guides for patients. This was done to alert health care professionals and patients that these medicines may increase the chance of severe asthma episodes, and death when those episodes occur. On February 18, 2010, the FDA further recommended that these medications be used only in combination with inhaled steroids; they should NOT be used as the only medicine to control asthma. All of these products contain long-acting beta2-adrenergic agonists (LABA). Even though LABAs decrease the frequency of asthma episodes, these medicines may make asthma episodes more severe when they occur. A Medication Guide with information about these risks will be given to patients when a prescription for a LABA is filled or refilled. See the FDA website for more information, at www.fda.gov.
- Leukotriene modifiers -- These are relatively new drugs for patients with mild-to-moderate persistent asthma. They come in tablet or pill form. For mild asthma, they may be considered as an alternative to inhaled steroids. For moderate asthma, they may supplement inhaled steroids in place of long-acting beta agonists. Leukotriene modifiers include monoleukast (Singulair), approved for children 12 months of age and older; zafirlukast (Accolate), for kids age 5 and older; and zileuton (Zyflo), for patients age 12 and older.
- IgE blockers -- This new class of drug targets immunoglobulin E (IgE), a molecule responsible for allergic asthma. Omalizumab (Xolair) is used for people with moderate or severe persistent asthma who continue to have symptoms as theirmedications are not completely controlling their asthma. Omalizumab (Xolair) is given by injection.
- Theophylline -- This drug is used to help control mild-to-moderate persistent asthma, especially to prevent nighttime symptoms. People who take this drug need routine blood tests to make sure that the drug stays within safe levels. Theophylline works by relaxing the muscles of your bronchial tubes; it is not an anti-inflammatory drug. Theophylline is used less often than it was in the past. Brands include Uniphyl.
- Cromolyn -- This is a non-steroid medicine with anti-inflammatory effects and may be used to control mild persistent asthma. Cromolyn is available for use in a nebulizer, and therefore may be appropriate for young children. It is also available as an aerosol. An example of cromolyn is Intal.
Combination therapy
For moderate persistent asthma and for severe asthma in children over age 5 and in adults, strong evidence from clinical trials clearly shows that adding a long-acting beta agonist to low-to-medium doses of inhaled steroids decreases the frequency of asthma episodes and reliance on relief medicines. This is because the steroid treats inflammation at the same time the beta agonist treats airway constriction (tightening). The combination approach is recommended for many patients. The U.S. Food and Drug Administration (FDA) recommends these medicines be used for as short a time as possible to get asthma symptoms under control, and they they be used only in combination with inhaled steroids.
The two available LABA drugs, formoterol and almeterol, can be taken with different inhalers, but products that combine them into one inhaler (such as Advair HFA, Advair Diskus, or Symbicort) may be more convenient and therefore used more consistently. Advair Diskus is a dry powder inhaler. Both Advair and Symbicort are approved for ages 12 and older.
Note: On November 18, 2005, the FDA notified manufacturers of Advair Diskus, Foradil Aerolizer, and Serevent Diskus to update their existing product labels with new warnings and later approved new safety labeling and Medication Guidse for patients. This was done to alert health care professionals and patients that these medicines may increase the chance of severe asthma episodes, and death when those episodes occur. All of these products contain long-acting beta2-adrenergic agonists (LABA). Even though LABAs decrease the frequency of asthma episodes, these medicines may make asthma episodes more severe when they occur. A Medication Guide with information about these risks will be given to patients when a prescription for a LABA is filled or refilled. See the FDA website for more information, at www.fda.gov.
For some patients, it may be appropriate to combine inhaled steroids with leukotriene modifiers or theophylline or to double the steroid dose alone. However, the evidence for the effectiveness of these combinations is not as substantial.
References
National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2007. NIH publications 08-4051.
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Reviewed By: Allen J. Blaivas, DO, Clinical Assistant Professor of Medicine UMDNJ-NJMS, Attending Physician in the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Veteran Affairs, VA New Jersey Health Care System, East Orange, NJ. Review provided by VeriMed Healthcare Network. Previoulsy reviewed by David A. Kaufman, MD, Section Chief, Pulmonary, Critical Care & Sleep Medicine, Bridgeport Hospital-Yale New Haven Health System, and Assistant Clinical Professor, Yale University School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Network. (6/1/2010)
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