Medications Used in the Treatment of Asthma

The following is a discussion of some of the types and classes of medications used in the treatment and maintenance of asthma.
Asthma has in the past been classified into one of four categories:

-Mild intermittent
-Mild persistent
-Moderate persistent
-Severe persistent

The newer asthma guidelines stress more of a "step up/step down approach", meaning the emphasis is on attaining symptom control with as little medication as possible, and to lower doses wherever possible.
The clinician is able to do this by incorporating something called "environmental control" in each and every asthmatic patient they diagnose. What this does is identifies the CAUSE of symptoms, so we can help to minimize it along with medications if necessary. Most commonly it is induced by allergy. 60% of adults, and up to 90% of children with asthma have allergic triggers. So, as part of treatment, we need to assess the patients asthmatic triggers by taking a thorough history and testing for allergies at EVERY LEVEL of asthma. Patient education, in my estimation, is the single most important tool we have for handling disease. The patient has more responsibility then we do- they're living with their disease- so why not give them all the tools they might need?

For all intents and purposes, I will discuss treatment based on the categories listed above. These are general guidelines, and may not be patient specific.

Mild intermittent

These are the patients that are having symptoms- cough, shortness of breath, wheezing, chest tightness- only on occasion. They need both a short-acting bronchodilator, also called a rescue inhaler. This is usually a brand of something called albuterol. Regardless of at what level of asthma the patient is diagnosed as having, or the level of severity, they need a rescue inhaler to be used only when they have an exacerbation (an attack). This opens up a constricted airway in a matter of seconds to minutes. It works quickly, but the effects don't last very long. If the patient finds that they're using this rescue inhaler too frequently, they may need to be stepped up on medications, and move to a "maintenance" medication. Of course, as every level of asthmatic gets a rescue inhaler, every level of asthmatic needs a trigger assessment....allergy testing, etc....to not only treat with medications, but minimize cause of symptoms wherever possible.

Mild Persistent

These are patients that have moved from having symptoms only occasionally, to having symptoms with some kind of regularity. There are three types of persistent asthmatics- mild, moderate, and severe, depending on how severe and how regular they have symptoms. Mild persistent asthmatics have symptoms infrequently, but on some kind of regular basis- maybe a couple of times a month or more. After assessing the patients history, physical exam, and pulmonary function testing (see previous blog), a treatment regimen is suggested. This regimen consists of allergy testing, a rescue inhaler, AND a maintenance medication- a drug the patient needs to take daily. A daily medication will help decrease attacks, with the help of minimizing exposure to the offending allergen. Suggested classes of medications include an inhaled steroid and a low or medium dose, or a leukotriene inhibitor, which works similarly to an antihistamine.

Moderate Persistent

At this level of asthma, the patient is having regular symptoms, some of them severe. These happen more than once a week of average, and inhibit work, school, sleep, play, and most other activities. These patients may have had one or two emergency room visits, and hospital stays for their asthma.
Along with a rescue inhaler, and allergy testing to reduce asthmatic triggers, this patient needs a medium dose inhaled steroid, or a combination medication inhaler, possibly plus a leukotriene inhibitor. A combination inhaler contains two types of medications- a long acting bronchodilator (which will open your airways for longer periods then will a rescue inhaler, but is NOT to be used as a rescue inhaler) and an inhaled steroid. Our goal, eventually, is to minimize the use of medications at this and every level, but these patients need something to use to decrease inflammation, being one of the causes of airway constriction.

Severe Persistent

These patients are classified at the most severe level of asthma. They are having regular, frequent symptoms of a severe nature, possibly some that are life-threatening. They most likely have had multiple emergency room visits, frequent rescue inhaler refills, and more than one life-threatening asthma attack.
Here, along with allergy testing and a rescue inhaler, these patients need a high-dose combination inhaler, a leukotriene inhibitor if positive for allergies, and possibly an oral steroid to help reduce inflammation. Oral steroids are a potent medication, and are usually used in bursts- short courses to quickly reduce inflammation. There are significant long term side effects, so we try not to use unless absolutely necessary. There are some patients that have to be on oral steroids daily, but only in the most severe cases.
There is another medication for the most severe of patients, that do in fact have allergic triggers. It is an injectable drug called omalizumab. This is very expensive medication, costing the insurance companies approximately $600 per injection, patients take 1-6 shots per month.
This is usually reserved for the allergist or pulmonologist to administer, being that they are seeing the most severe patients.

The common features of every level of diagnosed asthmatic are:

-The necessity of a rescue inhaler
-Testing for allergies- 60% of adults and 90% of children with asthma have allergic triggers
-Patient education. This may be the single most important aspect of treatment. How to use their medications, how the meds work, what in their environment to control, how to differentiate between an asthma attack and something else entirely (an anxiety attack, etc) and when to seek medical help.

I hope this was useful!

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