Asthma treatments
Asthma treatment usually involves managing your asthma with medications, as advised by your doctor.
Medications for asthma are divided primarily into ‘relievers’, ‘preventers’ and ‘symptom controllers’. Most asthma medicines are delivered by an inhaler device, although some are available in tablet or liquid form, or for people in hospital, by injection.
Relievers
Short-acting beta2 agonists
These types of reliever medications include salbutamol (e.g. Airomir or Ventolin) and terbutaline (e.g. Bricanyl). These medications are known as bronchodilators because they help to open up the airways, helping you to breathe more easily when you're having difficulty.
In general, relievers should be used on an ‘as-needed’ basis for the relief of asthma symptoms. However, if you get exercise-induced asthma, your doctor might recommend that you inhale one or 2 measured doses of your reliever before exercise.
If you find that you're using your reliever more than 3 times a week, you should consult your doctor, who may recommend introducing a preventer medication.
And if you're finding that your usual dose of reliever medication isn't offering as much relief as it used to, you should see your doctor for advice and a review of your treatment, as this indicates that your asthma may be getting worse.
Theophylline
Short-acting beta2 agonists are the most common types of bronchodilators doctors prescribe but there are others, including theophylline (e.g. Nuelin tablets or syrup), one of the older asthma medications, which can be used to relieve or help prevent asthma symptoms. The use of theophylline has declined but it is still sometimes used to help people with persistent asthma who need multiple medications to control their condition.
Anticholinergic bronchodilators
Anticholinergic bronchodilators, such as ipratropium (e.g. Atrovent), work by blocking the nerve reflexes that cause the airways to constrict, thereby allowing the airways to remain open. Anticholinergic bronchodilators are sometimes used in combination with beta2 agonists. However, ipratropium has a slow onset of action and is more commonly used in the treatment of chronic obstructive pulmonary disease (COPD) than in the treatment of asthma.
Preventers
Inhaled corticosteroids
The main types of preventer medications for asthma are inhaled corticosteroids such as beclomethasone (e.g. Qvar), budesonide (e.g. Pulmicort), ciclesonide (e.g. Alvesco) and fluticasone (e.g. Flixotide).
These work by reducing the underlying inflammation of the airways, helping to reduce the incidence and severity of episodes of asthma. Unlike reliever medication, you should take your preventer every day, as prescribed by your doctor, to help keep your asthma under control.
Like all medications, there can be some side effects with inhaled corticosteroids. Unwanted effects include oral thrush (a fungal infection of the lining of the mouth or throat) and perhaps some hoarseness. These can be reduced and prevented by using a spacer device to deliver the medication and rinsing the mouth with water after using an inhaled corticosteroid.
Long-term use of high doses of inhaled corticosteroids may result in significant doses of the medication being absorbed into the bloodstream. This leads to an increased risk of easy bruising, osteoporosis (screening is advised for adults on long-term high-dose inhaled corticosteroids) and, in children, it may rarely cause adrenal suppression.
There has been some concern about growth suppression in children who take inhaled corticosteroids, but this is usually only when high doses are used. Poorly controlled asthma itself can also cause growth suppression.
If you are concerned, discuss treatment with your doctor.
Oral corticosteroids
If your asthma is severe or you have an attack which is not controlled by reliever medications and inhaled steroids, you may be prescribed oral steroids such as prednisolone (e.g. Panafcortelone tablets, Redipred oral liquid or Predmix oral liquid) or prednisone (e.g. Panafcort tablets).
These are usually given as a short course to help settle your asthma. In general, these medications are used for prolonged periods only under the supervision of a respiratory physician.
Leukotriene receptor antagonists
Leukotriene receptor antagonists, such as montelukast sodium (e.g. Singulair tablets) or zafirlukast (e.g. Accolate tablets), are different from corticosteroids: they work by blocking substances in your lungs called leukotrienes, which cause narrowing and swelling of the airways. Blocking leukotrienes can improve asthma symptoms and can help prevent asthma attacks.
Leukotriene receptor antagonists are not used to treat an acute attack of asthma. They are preventers and should be taken daily, as prescribed by your doctor.
Other non-steroidal anti-inflammatories
Medications such as sodium cromoglycate (e.g. Intal, Intal Forte) and nedocromil sodium (e.g. Tilade) are non-steroidal anti-inflammatory asthma medications. Each type of medicine works differently but, in general, they are thought to work by helping to prevent the release of substances (inflammatory mediators) that contribute to the inflammation and narrowing of the airways.
These preventers are delivered by inhaler, and are taken daily as prescribed by your doctor. They have a variety of uses including prevention of asthma symptoms triggered by exercise, cold air, inhaled allergens, pollutants or other irritants. They are not for use in relieving an acute asthma attack.
Anti-immunoglobulin therapy
Omalizumab (Xolair) is an injection that works to block a substance called immunoglobulin E (IgE) that is involved in causing asthma symptoms. IgE is produced by the body in response to allergens, such as cat dander. Your doctor may need to do a blood test to measure the amount of IgE before starting treatment. Xolair is used in the treatment of adults and adolescents over 12 years with moderate to severe allergic asthma who are already taking inhaled corticosteroids and who have raised serum levels of IgE.
Symptom controllers
Long-acting beta2 agonists
Symptom controllers (long-acting beta2 agonists or LABAs) are useful for people with asthma who find that their asthma is still not controlled even though they are taking their preventer medication.
Examples of symptom controllers include salmeterol (e.g. Serevent) and eformoterol (e.g. Oxis or Foradile).
Symptom controllers don't treat the underlying inflammation of the airways so they should be used in addition to preventer medication: they are not a substitute for corticosteroids.
The advantage of symptom controllers is that they can keep the airways open for up to 12 hours after you take them. Salmeterol does not open the airways immediately, so when you're having asthma symptoms you should still use your reliever medication to help relieve your symptoms immediately. However, eformeterol opens the airways more rapidly, so can be used as a reliever medication in adults. You should talk to your doctor about the most appropriate treatment for your asthma symptoms.
Combination products
Some asthma products contain a combination of a corticosteroid (preventer) and a long-acting beta2 agonist (symptom controller), to help keep asthma under control.
Combination products that your doctor might prescribe include Seretide (a combination of the preventer fluticasone and the symptom controller salmeterol) and Symbicort (a combination of the preventer budesonide and the symptom controller eformoterol). These combination products are delivered by inhaler, usually twice daily.
Devices
Inhaled medicine must be delivered to the lungs in an adequate dose. To ensure effective delivery a number of devices have been developed.
Metered dose inhalers
One of the standard inhaler devices is the pressurised metered dose inhaler (MDI), commonly known as a ‘puffer’. MDIs require co-ordination and good timing between activation (pressing down on the inhaler) and inhalation. Most adults and children older than about 7 years can be taught to use MDIs correctly but technique can deteriorate over time. You should check your technique with your pharmacist or doctor periodically.
MDIs should be washed regularly. The metal canister should be removed and the plastic casing washed by rinsing the mouthpiece through the top and the bottom under warm running water for at least 30 seconds. Next, wash the mouthpiece cover. These should be allowed to dry in the air (NOT with a towel or tissue) before being put back together. Most MDIs should be washed at least weekly; the Asthma Foundation of Australia recommends that Intal Forte and Tilade inhalers should be washed and air-dried every day.
Spacers
Spacers are excellent devices to help improve delivery of inhaled medication to the lungs.
A spacer is a large, plastic device which acts as a holding chamber for medication for the few seconds that might elapse between activating your MDI and breathing in the medication. By putting one end of the spacer in your mouth and attaching your MDI to the other end of the spacer, you can inhale your medication effectively without having to press the MDI and breathe at exactly the same time.
Spacers are usually recommended for children of all ages: children under 2 years will need a small-volume spacer and face mask; children 2-4 years will need a small-volume spacer and a mouthpiece or face mask; and children 5-7 years can use a large-volume spacer. A doctor might also recommend a spacer for adults who have poor co-ordination when using MDIs, or for people who are taking inhaled corticosteroids by MDI, as spacers can help to reduce adverse effects such as oral thrush. A spacer is also useful to deliver your reliever medication when you're having an acute attack. Because using a spacer improves the effectiveness of the medication, their use has meant very few people now need nebulisers.
Spacers should be washed monthly, otherwise performance can be adversely affected. They should be washed in warm water with kitchen detergent and left to drain and air dry. Do not dry your spacer with a cloth or tissue as this produces static build-up that makes the medication stick to the sides. If this happens your lungs will not receive the full dose. The mouthpiece should be wiped clean of detergent.
Correct use of a spacer is important so you should check your technique with your doctor or pharmacist regularly.
Breath-activated powder devices
These come in a variety of forms (e.g. Turbuhaler, Accuhaler, Aerolizer, and Rotahaler) and they work by releasing the medication only when you breathe in. These devices usually require less co-ordination than MDIs, but they do require a certain level of inspiratory breath to activate them.
Nebulisers
A nebuliser is a machine that bubbles air through a solution of a medication (such as a reliever medication) to create a vapour that can be breathed in through a mouthpiece or a face mask. In general, nebulisers are used only for emergencies or for very severe asthma.
Choosing a device
Selection of the type of device is often a personal preference; some people prefer a pressurised MDI to a breath-activated device and vice versa. However, the individual device you use can depend on the medication you're taking, as medication manufacturers often present their medicine in their own type of device. For example, if you're taking Bricanyl, Pulmicort or Oxis, and you prefer a breath-activated device, you will receive a Turbuhaler, but if you prefer a breath-activated device and you're taking Serevent or Flixotide you will receive an Accuhaler.
Complementary therapies
A condition such as asthma usually requires treatments prescribed by a doctor. However, some people choose to use complementary medicines and therapies as well. Always remember to tell your doctor about any complementary medicines or supplements you may take as they may interact with your other medicines.
Among the therapies that people have tried are:
- complementary medicines, although definitive published research is still lacking. Some herbal remedies, such as ginkgo biloba, have been identified as potential agents for further research as asthma treatments, although ginko can have safety issues and can interact with some medicines. Other agents, such as Royal Jelly and echinacea can precipitate life-threatening allergic reactions in predisposed people with asthma, and should not be taken if you have asthma or allergies;
- breathing techniques, such as the Buteyko technique — some studies have shown a subjective improvement of symptoms and reduction in use of reliever medication;
- relaxation techniques, such as yoga — the evidence for a benefit in asthma is inconclusive;
- acupuncture — current evidence doesn't support it as treatment for asthma;
- hypnosis (hypnotherapy);
- homeopathy, which can involve preparing a medicine that includes a tiny amount of the element that triggers an allergic reaction, such as house dust mites and then diluting it until no trace of the element remains — currently, the evidence from trials suggests that homeopathy is ineffective in treating asthma;
- dietary modification — people with diagnosed food allergies should avoid certain foods, however, routine dietary restrictions in people with asthma have not been shown to be beneficial. Some food supplements, such as fish oils may offer benefit in asthma.
Most complementary therapies have not been researched as extensively as more conventional medications for asthma, so if you are thinking of adding complementary medicines or therapies to your asthma management programme, you should consult your doctor for advice first.
Asthma action plans
If you have asthma, you should also have your own written asthma plan, devised in conjunction with your doctor.
This will help you to manage your asthma and identify when your asthma is getting worse by recognising your symptoms, understanding your peak flow readings and understanding your asthma medications.
The asthma action plan should also help you to recognise when you need to adjust your asthma medications, when to contact your doctor and when to go directly to hospital.
Last Reviewed: 07 September 2009
- 1. National Asthma Council Australia. Asthma management handbook 2006 [accessed 2009, Sep 18]. Available from: http://www.nationalasthma.org.au/cms/index.php
2. eMIMS Prescribing Information, October 2009
3. Asthma Foundations of Australia. Asthma medications and delivery devices [published 2008; accessed 2009, Sep 18]. Available at: http://www.asthmansw.org.au/assets/265/File/Brochure_Medications_Devices_2008.pdf
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