Corticosteroids

Corticosteroid medications for long-term asthma control can be taken orally or inhaled. The oral form typically is used only when long-term control cannot be obtained with inhaled corticosteroids.

Inhaled corticosteroids are used to treat all categories of asthma except the mild intermittent type. They work primarily by reducing inflammation in the asthmatic airway. They also increase receptors for the beta2 agonists and decrease microvascular leaking, which contributes to increased fluid in the bronchial tubes. These factors are felt to be of minor importance compared to the anti-inflammatory benefit.

Oral corticosteroids usually are used only in patients who have severe persistent asthma. They also can be used to treat acute exacerbations, although this use is not common. As with inhaled corticosteroids, their main mechanism of action is the reduction of inflammation.

Cromolyn sodium and nedocromil

These anti-inflammatory agents are delivered by inhalation. They are safe and have minimal side effects, apart from an unpleasant taste. They may be used as long-term anti-inflammatory medications and work best in children.

Cromolyn sodium and nedocromil are not as predictably effective as corticosteroids, and should be discontinued if found to be ineffective. They can be used prior to exercise to prevent exercise-induced asthma.

Leukotriene modifiers

Leukotriene modifiers (leukotriene receptor antagonists; e.g., Singulair, Accolate) are a class of drugs that block part of the inflammatory cascade that typically occurs in asthma. These drugs, which are taken orally, can be prescribed for adults and children 2 years of age and older.

They often are used with inhaled corticosteroids and should not be used to treat an acute asthma attack. Singulair also is approved to prevent exercise-induced asthma in patients over the age of 15. Side effects include the following:

  • Dizziness
  • Fatigue
  • Fever
  • Headache
  • Stomach upset

Rare side effects include Churg Strauss syndrome, kidney problems, and elevated liver enzymes.

Long-acting beta2 agonists

Long-acting beta2 agonists relax bronchial smooth muscle, similar to the short-acting beta2 agonists. They work more slowly, however, and for this reason they aren't considered good rescue medications.

The body can develop a slight tolerance to long-acting beta2 agonists over time, which may render them slightly less effective. They usually are used with inhaled corticosteroids to control symptoms and are particularly useful for treating nocturnal symptoms and exercise-induced asthma. The side effects are the same as those of short-acting beta2 agonists: tachycardia (rapid heartbeat), skeletal muscle tremor, hypokalemia, increased lactic acid, headache, and hyperglycemia.

Theophylline

Theophylline acts as both a bronchodilator and an anti-inflammatory. It usually is used in addition to beta2 agonists and other anti-inflammatory drugs.

Bronchial Thermoplasty

In 2010, the U.S. Food and Drug Administration (FDA) approved an additional treatment option for adults (over the age of 18) who have severe, persistent asthma that does not respond to other therapies. This treatment device, called the Alair Bronchial Thermoplasty System, consists of a small tube (catheter) with an electrode that delivers electromagnetic energy through a bronchoscope to the airways and a control unit that produces and regulates the energy.

This device allows the physician to treat areas of lung tissue—reducing smooth muscle and preventing excessive airway constriction that occurs during an asthma attack. The goal of treatment, which is adminstered under moderate sedation or light anesthesia, is to reduce severe asthma symptoms over time. Treatments are given on an outpatient basis and consist of three sessions—each targeting different areas of the lungs—usually scheduled about 3 weeks apart.

Possible side effects of bronchial thermoplasty include worsening asthma symptoms (e.g., wheezing, chest discomfort, chest pain), partial lung collapse (atelectasis), bleeding in the lower airways (hemoptysis), anxiety, headaches, and nausea. Patients who have an implanted electronic device (e.g., pacemaker, defibrillator), a known sensitivity to medications (e.g., lidocaine, atropine, benzodiazepines) that are necessary to perform bronchoscopy, and those with respiratory infections or blood clotting disorders should not receive bronchial thermoplasty.

Mepolizumab (Nucala) Injection

The FDA approved mepolizumab in November 2015 to treat adults and children over the age of 12 who have a history of severe asthma attacks in spite of treatment. It is used with other medications as part of a long-term maintenance program. Nucala is an interleukin-5 antagonist that is administered via subcutaneous injection once every 4 weeks.

In clinical trials, this medication reduced the number of exacerbations requiring hospitalization or emergency asthma treatment, and increased the length of time until the next exacerbation. According to research, Nucala does not substantially improve lung function.

Common side effects include back pain, fatigue, weakness, and injection site reactions (e.g., pain, redness, swelling, etc.). Serious reactions such as hypersensitivity (fainting, dizziness, lightheadedness, and swelling of the face, mouth, or tongue) may occur within hours or days of treatment with Nucala. Infection with the virus that causes shingles (herpes zoster) also has been reported.

Updated by Remedy Health Media

Publication Review By: Stanley J. Swierzewski, III, M.D.

Published: 31 May 2000

Last Modified: 06 Nov 2015