Asthma Treatment

Asthma is a chronic lung disease. There are 25 million people with asthma living in the United States. This includes 20 million adults and 5 million children. Asthma causes episodes of coughing, wheezing, chest tightness and shortness of breath. Symptoms can be mild or severe, and sometimes life-threatening. While asthma cannot be cured, understanding “what is asthma” and adhering to effective asthma treatment can lead to successful asthma management.

Treatment for asthma primarily focuses on managing symptoms along with preventing and treating asthma attacks. Different asthma treatments have different roles. It is important to understand your treatment and its roles in helping control your asthma.

Asthma medications

There are four basic types of asthma medicines:

1. Bronchodilators relax and open the airways to relieve asthma symptoms.
2. Controller medications (anti-inflammatory) are used to reduce and prevent lung inflammation.
3. Combination inhaler medications combine more than one asthma medication in one device.
4. Biologics are medications that target the specific cells and pathways that cause inflammation related to severe asthma.

Work with your healthcare provider to find the right combination of medications for optimal asthma control. You may need to adjust the type and amount of medication based on your symptoms, asthma test results, and the type of asthma you have.

Remember, the goal of asthma treatment is to have you feel your best with the least amount of medication needed to control asthma.

Bronchodilators

Bronchodilators relax and open the airways to relieve asthma symptoms. This helps with symptoms such as coughing, wheezing, chest tightness and shortness of breath. Bronchodilators can be both short-acting or long-acting.

What are the different types of bronchodilators for asthma?

1. Short acting beta-agonist bronchodilators (quick relief): You may sometimes hear these referred to as short-acting beta-agonists, or SABA. These include albuterol and levalbuterol. With these quick-relief medications, symptom relief starts almost immediately and lasts 3-6 hours. This is the medicine you will be told to use if you are experiencing a sudden onset of symptoms or an asthma attack. Some people call quick-relief inhalers their “rescue inhaler” because it helps “rescue” you from the symptoms of an asthma attack.
2. At times, healthcare providers will prescribe quick-relief medications to prevent exercise-induced bronchospasm (EIB) – also called exercise-induced asthma. The quick-relief inhaler can be used 15-20 minutes before exercise to help prevent asthma symptoms.
3. Long-acting beta-agonist bronchodilators: These medications relieve symptoms for 12 to 24 hours. You may also hear these referred to as long-acting beta-agonists, or LABA. Long-acting beta-agonists for asthma include formoterol, salmeterol, and vilanterol. They are typically used in combination with an inhaled corticosteroid.
4. Long-acting muscarinic antagonist (LAMA): These are anticholinergic medications that are mostly prescribed for COPD, but a few are approved for severe asthma as well. Tiotropium and umeclidinium are approved for asthma and are typically used in combination with an inhaled corticosteroid.

Controller medications

Anti-inflammatory medications treat and prevent airway inflammation and swelling. They also reduce mucus. These medications usually need to be taken every day to prevent and control symptoms. They are helpful with preventing asthma attacks.

After using an anti-inflammatory medication, you may not feel different right away. That’s because it takes time for airway swelling to subside and the mucus to clear out of the airways. Keep using the medication as directed, even if you don’t feel anything happening right away.

What are different types of controller medications for asthma?

1. Inhaled corticosteroids (beclomethasone, budesonide, ciclesonide, fluticasone, mometasone) are effective long-term asthma control medications. Taken as prescribed, they can reduce excess mucus. They also prevent airway swelling. Because the medication is inhaled, the medicine goes directly to the inflamed airways.
    
   Note: Always use inhaled corticosteroids as prescribed; do not stop using them even when you are symptom-free and feeling well.
2. Leukotriene modifiers are oral medications that block the action of leukotrienes. Common leukotriene modifiers include montelukast, zafirlukast, and zileuton. Leukotrienes are chemicals involved in immune system responses. These responses cause inflammation, swelling and tightening of the airways. They are available as granules, chewable or tablets. Leukotriene modifiers should not be used to treat sudden symptoms or asthma attacks.Montelukast may cause behavioral side effects. These may include sleep disturbances, anxiety, depression, confusion, sudden mood changes and suicidal thoughts or actions. Talk with your healthcare provider about these potential side effects before taking montelukast. If you’re prescribed it, monitor for side effects during treatment.
    
3. Oral corticosteroids are used to treat acute asthma flares. They are usually prescribed only for short periods of time (5-7 days). Taken as prescribed, they gradually reduce asthma symptoms and open the airways.The dosage of oral corticosteroids is 10 times the dose of inhaled corticosteroids. As a result, there is an increased risk of side effects. These may include weight gain, insomnia, headaches, and easy bruising of the skin. Side effects may also include behavioral problems, moodiness and depression.If taking oral corticosteroids long-term, side effects can be even more problematic. Side effects from long-term use may include eye problems, onset of diabetes, increased risk of infections and thinning bones. Patients should talk with their doctor about the risks vs. benefits of long-term oral corticosteroid use.When you hear the term “steroids” in asthma care, they are referring to corticosteroids. These are NOT related in any way to the anabolic steroids used illegally in body building.

Combination medications

Combination medications combine two or even three medications into one inhaler. The devices may contain an anti-inflammatory inhaled corticosteroids, a SABA, LABA or LAMA. Combination medications are typically used daily.

What are different types of combination medications for asthma?

1. Inhaled corticosteroids and LABA combinations: typically taken on a daily basis to control asthma symptoms. Most are taken once every 12 hours. One is taken once a day. These medication combos include budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, and mometasone/formoterol.
    
2. Inhaled corticosteroid, LABA and LAMA combination: there is one combination inhaler with these three medications approved for use in asthma. Medications in this inhaler include fluticasone/umeclidinium/vilanterol. It is typically taken once a day.
    
3. SMART therapy: SMART stands for single maintenance and reliever therapy. It combines an inhaled corticosteroid and an inhaled LABA (formoterol) in one inhaler. This allows people with asthma to use a SMART therapy inhaler as a controller (maintenance) medication and for quick-relief for acute asthma symptoms.
4. Inhaled corticosteroid and SABA combination: this medication is FDA-approved and it is expected to be available in 2024. The medications in this inhaler are budesonide and albuterol. It is taken for treatment or prevention of bronchoconstriction and as a controller to prevent asthma symptoms.

Biologics

Biologic medications target cells, pathways and proteins that cause inflammation in the body. These medications focus on treating the source of symptoms rather than the symptoms themselves. They aim to stop symptoms before they can start by targeting inflammation in the body at its source.

Biologics are typically prescribed as an add-on therapy for severe asthma. This means you continue to take a daily controller medication in addition to the biologic.

Biologics are usually administered as an injection every 2 to 8 weeks. (One biologic is available as an infusion.) They are not used to treat asthma attacks. Biologics are intended to help patients gain long-term asthma control. They help improve asthma by reducing inflammation and the risk of an asthma attack.

What are different types of biologics for asthma?

1. Anti-IgE biologics work to interrupt a protein (antibody) called IgE. This antibody is part of the allergic response to an allergen and the start of the inflammatory process. The medication in this category is omalizumab.
    
2. Eosinophil reduction biologics work to decrease eosinophils (part of the white blood cell) in the body that promote inflammation. These medications include benralizumab, dupilumab, mepolizumab and reslizumab.
    
3. TSLP (thymic stromal lymphopoietin) blockers work by blocking cytokines from starting airway inflammation. The medication in this category is tezpelumab.

What is bronchial thermoplasty?

Bronchial thermoplasty is an outpatient surgical procedure. It is for adults ages 18 and older with poor asthma control. These people have severe persistent asthma symptoms despite using standard therapy.

The procedure is performed in three outpatient visits under moderate or general anesthesia. A pulmonologist or other qualified physician inserts a long, slender tube called a bronchoscope into the lungs and surrounding airways. They then heat and shrink the size of muscle tissue. This allows more air to pass through and make breathing easier.

Side effects may include a short-term worsening of asthma symptoms. These side effects usually resolve within a week.

If you have severe and difficult-to-control asthma, talk with your doctor to determine if bronchial thermoplasty is right for you. Be sure to check your health insurance to confirm if the procedure is covered.

How are inhalers used to treat asthma?

Many asthma medicines are delivered using an inhaler or a nebulizer. Inhalers and nebulizers are devices that allow the asthma medications to be inhaled through your mouth. This means you breathe the medicine in, and it goes straight to the airways. There are four types of inhaler delivery devices:

• Metered-dose inhaler (MDI): pressurized devices that release medication in a fine spray for you to inhale
• Dry powder inhaler (DPI): releases medication as a fine powder for inhaling
• Breath-actuated Inhaler: a dry powder or a non-pressurized inhaler
• Slow-moving mist inhaler: similar to an MDI, but with a slower-moving mist

How do I reduce the need for medications?

Sometimes asthma symptoms seem to come out of nowhere. Other times, you can predict them. You can make sense of this asthma rollercoaster by tracking when and how symptoms happen.

Learn the early warning signs of an asthma attack. If you know what to look for, you will notice when an asthma attack is developing. These signs will vary from one person to another. But it can be as simple as a tickle in the throat or chest, a sharp or sudden cough, or a feeling of extreme tiredness.

This is important because it takes less medication to stop symptoms from worsening than it does to treat a full-blown asthma flare-up. By the time you begin to cough or wheeze, your lungs are already congested and compromised. That’s why you need to pay close attention to the subtle signs.

Follow the asthma treatment plan prescribed by your healthcare provider and be aware of your triggers.

How understanding asthma triggers can help with treatment

Part of asthma management involves understanding your asthma triggers. An asthma trigger is something that can cause a flare-up or make your symptoms worse. For some people, an asthma trigger may be pollen. For another, it may be exercise or cold air. For someone else, it may be pet dander or dust mites. Some people find that respiratory infections, such as a cold, COVID -19 or the flu, trigger symptoms. Every person has different asthma triggers.

When you learn your asthma triggers, you’ll find ways to reduce your need for asthma medications. Notice your triggers in your home, work or school. Then try your best to avoid contact with them or plan for preventative treatment. To benefit from your medication, it must be taken at the right dose, at the right time and in the right way. Since there can be obstacles to any of these steps, review your Asthma Action Plan at every doctor’s visit. Demonstrate your inhaler delivery technique to be sure that you are taking medication correctly.

If your asthma symptoms persist, talk with your healthcare provider about the need to adjust your medications. Discuss any concerns over cost. Any barrier to accessing or using your medication can affect your asthma control.

How do I know if my asthma is under control?

If you start to regularly experience symptoms during everyday activities, visit an asthma specialist to discuss whether you need to adjust your treatment plan. Discuss any problems you may have controlling your asthma.

The Rules of Two®, Asthma Control Test™ (ACT) and The Asthma Impairment and Risk Questionnaire (AirQ®) are ways to find out if your asthma is under control.

Rules of Two^®

If you answer “yes” to any of these questions, make plans to visit your asthma specialist:

• Do you need to use your quick-relief inhaler TWO or more times a week? (except to prevent symptoms before exercise)
• Does your asthma wake you up TWO or more times a month? (Nighttime symptoms are a sign of nocturnal asthma)
• Do you refill your quick-relief inhaler TWO or more times a year?
• Do you use prednisone TWO or more times a year for flares of asthma?
• Does your peak flow vary at more than TWO TIMES 10 (20%) from baseline when you have asthma symptoms?

The Rules of Two® is a registered trademark of the Baylor Healthcare System.

Asthma Control Test™ (ACT)

The Asthma Control Test is a 5-question Q&A that helps you and your doctor determine whether your asthma is controlled. The test asks:

• how often you have experienced symptoms in the past four weeks;

• how often you have needed your quick-relief albuterol inhaler in the past four weeks;

• what impact symptoms have had on your life and your ability to sleep in the past four weeks.

Share the ACT score with your healthcare provider as a starting point for a conversation about managing asthma. A Childhood Asthma Control Test* is also available.

Asthma Impairment and Risk Questionnaire (AirQ)

The Asthma Impairment and Risk Questionnaire assesses a patient’s asthma control. It comes in a “Yes/No” format and designed for adults and children ages 12 and older. The questionnaire asks if coughing, wheezing, shortness of breath or chest tightness have:

• bothered you and/or limited your activities (including exercise and social events) and ability to sleep in the past two weeks;

• caused you to use your quick-relief albuterol in haler in the past two weeks;

• caused you to take oral corticosteroids;

• caused you to go to the emergency department or hospital with symptoms

Share the AirQ score with your healthcare provider and begin a conversation about your asthma treatment.

Questions & Answers (Q&A) about asthma treatments

You may have specific questions about how to treat asthma. Here’s a Q&A with some of the more common questions about this condition. If there’s something you’d like to see covered, please email the editor.

Reviewed by:

Bradley Chipps, MD, FACAAI, is a board-certified allergist and pediatric pulmonologist with Capital Allergy and Respiratory Disease Center in Sacramento, California. He earned his medical degree from University of Texas Medical Branch in Galveston in 1972. He is Past President of the American College of Allergy, Asthma and Immunology (ACAAI).