Long-term control (maintenance) medications are taken on a regular basis to prevent asthma attacks, control inflammation in the airways, and manage chronic symptoms.
Corticosteroids, also called glucocorticoids or steroids, are powerful anti-inflammatory drugs. Steroids are not bronchodilators (they do not relax the airways) and have little immediate effect on symptoms. Instead, they work over time to reduce inflammation and prevent permanent injury in the lungs. They can also help prevent asthma attacks from occurring.
Taking a corticosteroid drug through an inhaler makes it possible to provide effective local anti-inflammatory activity in the lungs with very few side effects elsewhere in the body. (By contrast, oral steroids have considerable side effects throughout the body.) Inhaled corticosteroids (ICS) are recommended as the primary therapy for any patient needing long-term control medications for persistent asthma.
Examples of inhaled corticosteroids:
- Beclomethasone (QVAR), budesonide (Pulmicort), ciclesonide (Alvesco), flunisolide (AeroBid), fluticasone (Flovent), mometasone furoate (Asmanex), and triamcinolone (Azmacort and others).
- Budesonide (Pulmicort Respules) is available in a jet nebulizer for children ages 12 months to 8 years. It was the first such medication to be approved for children in this age group.
- Inhalers that combine both long-acting beta2-agonists and corticosteroids are also available. These include Symbicort (budesonide/formoterol), fluticasone-salmeterol (Advair), and mometasone-formoterol (Dulera).
Inhaled corticosteroids are the preferred first-line therapy for children with asthma. However, doctors caution against corticosteroids for infants and toddlers with mild asthma and urge close monitoring, especially for children under age 5 with severe asthma who are receiving high doses.
Inhaled corticosteroids and growth in children is a common concern. However, a number of studies report only a slight effect (about half an inch) on children's growth, which may be only temporary. These growth changes are mostly when higher doses are being used. Poorly controlled asthma can also affect growth.
Side effects of inhaled steroids may include:
- Throat irritation, hoarseness, and dry mouth (the most common side effects). Using a spacer device and rinsing the mouth after each treatment can minimize or prevent these effects.
- Rashes, wheezing, facial swelling (edema), fungal infections (thrush) in the mouth and throat, and bruising are also possible, but not common, with inhalators.
- Some studies have suggested a higher risk for gum inflammation.
- It is not yet known whether inhaled steroids affect lung development in very young children. Steroids administered using nebulizers are of particular concern.
Long-acting beta2-agonists (LABAs) are used for preventing an asthma attack (not for treating attack symptoms). These drugs should never be used alone in the treatment of asthma in adults or children. They can be dangerous when used alone, because they can mask asthma symptoms, and they can increase the risk of asthma death unless paired with an inhaled steroid. LABAs should only be used in combination with an asthma controller medication, such as an inhaled corticosteroid. LABAs should be used for the shortest time possible, and should only be used by patients whose asthma is not adequately controlled by asthma controller medications.
Salmeterol-fluticasone (Advair), formoterol-budesonide (Symbicort), and mometasone-formoterol (Dulera) are long-acting beta2 agonists products combined with a steroid in a single inhaler that are used for treatment of moderate-to-severe asthma. Advair is approved for children ages 4 years and older, and Symbicort and Dulera are approved for children ages 12 years and older.
Leukotriene antagonists (also called anti-leukotrienes or leukotriene modifiers) are oral medications used for prevention, NOT for treating acute asthma attacks.
Leukotriene antagonists include montelukast (Singulair, generic), zafirlukast (Accolate, generic), and zileuton (Zyflo). These drugs are considered an alternative for long-term control of asthma. Other potential uses include preventing exercise-induced asthma.
Side Effects and Complications. Upset stomach, headache, and sore throat are the most common side effects of leukotriene antagonists. Because these drugs can raise liver enzyme levels, patients may need periodic liver tests.
Leukotriene antagonists may cause mental health and behavioral changes. Mood problems include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking. Patients who take a leukotriene antagonist drug should be monitored for signs of behavioral and mood changes. Doctors should consider discontinuing the drug if patients exhibit any of these symptoms.
Omalizumab (Xolair) is FDA-approved for patients age 12 and older. It should be considered only for children over 12 years who have moderate-to-severe persistent asthma related to allergies and for adults who have severe asthma and allergies. Omalizumab is a biologic drug that targets and blocks the antibody immunoglobulin E (IgE), a chemical trigger of the inflammatory events associated with an allergic asthma attack.
Omalizumab is given by injection every 2 to 4 weeks. It is used only to treat patients whose symptoms are not controlled by inhaled corticosteroids.
Side Effects and Complications. About 1 in 1,000 patients who take omalizumab develop anaphylaxis (a life-threatening allergic reaction). Patients can develop anaphylaxis after any dose of omalizumab, even if they had no reaction to a first dose. Anaphylaxis may occur up to 24 hours after the dose is given.
Omalizumab should always be injected in a doctor’s office and health care providers should observe patients for at least 2 hours after an injection. Patients should also carry emergency self-treatment for anaphylaxis (such as an Epi-Pen) and know how to use it. With an Epi-Pen, or similar auto-injector device, patients can quickly give themselves a life-saving dose of epinephrine.
Anaphylaxis symptoms include:
- Difficulty breathing
- Chest tightness
- Itching and hives
- Swelling of the mouth and throat
The FDA is currently reviewing whether omalizumab may be associated with increased risk for heart and vascular problems (ischemic heart disease, arrhythmias, cardiomyopathy, heart failure, pulmonary hypertension, and blood clots).
Theophylline relaxes the muscles around the bronchioles and also stimulates breathing. Since the introduction of inhaled corticosteroids and long-acting beta2-agonists, theophylline is not used as often for asthma treatment. It may still be used in some circumstances, such as for treating severe or nocturnal asthma. Theophylline is available in tablet, liquid, and injectable forms. Theophylline should not be used by people with peptic ulcers or GERD, and should be used with caution by anyone with heart disease, liver disease, high blood pressure, or seizure disorders.
If a child is taking theophylline on an ongoing basis, the doctor should monitor the drug level at the start of therapy and at regular intervals thereafter.