Treatments for asthma depend on your age and on the severity of your condition. Because asthma severity may vary over time, treatment must be tailored to the individual patient and must be periodically revised.
Each person with asthma (adult, adolescent and child six years or over) should be prescribed asthma medication containing inhaled corticosteroid (ICS) to reduce the risk of severe attacks.
Each asthma patient should also receive a personalised asthma action plan that explains in detail the type of controller and reliever medicine to use as daily treatment and how to modify the medications in case of an attack.
Controller medicines keep your asthma under control by reducing the inflammation in your lungs and are therefore used to prevent attacks and airflow limitations. They include ICS with or without long-acting beta agonists (LABA). The right controller therapy prevents attacks, reduces the need of reliever medicines and, most importantly, minimises or eliminates the risk of severe attacks that may need to be treated with oral corticosteroids (OCS), thereby minimising possible severe side effects.
Reliever medicines are used as needed for day-to-day symptoms, and during an attack to open up the airways in the lungs. Reliever medicines can be either a combination of low-dose ICS and formoterol (a particular long-acting beta-agonist) or it can be a short-acting beta agonist (SABA).
Patients with mild asthma may be prescribed low-dose budesonide-formoterol for as needed use, without any maintenance controller. This reduces the risk of severe attacks compared with using a SABA alone. Patients with mild asthma who are prescribed a SABA reliever should take low-dose ICS any time you use the SABA reliever.
About asthma treatments: action and effects
Maintenance medications
Inhaled corticosteroids (ICS): These are anti-inflammatory drugs used for long-term control of asthma. They reduce swelling and tightening in your airways, control symptoms, improve lung function, and reduce the risk of severe attacks and of asthma deaths. These drugs will start to improve your asthma within hours or days, and your asthma may continue to improve for several months after you start taking them.
ICS in combination with long-acting beta agonists (LABA): Using a combination of ICS with a long-acting bronchodilator helps to reduce asthma symptoms and reduce the risk of attacks compared with a higher dose of ICS. LABAs must be taken only in combination with an ICS, since if they are used on their own, they can increase the risk of severe asthma attacks. There are two different types of ICS-LABA combinations: ICS combined with formoterol, and ICS combined with other LABAs such as with salmeterol or vilanterol.
Reliever medications
Short-acting beta-agonist (SABA): Reliever medications that open the lungs by relaxing airway muscles. They can relieve asthma symptoms temporarily. They begin working within minutes and are effective for four to six hours. They are not controller medications and they do not protect you from having another asthma attack. In fact, frequent use of SABAs may increase the risk of severe attacks and even death.
Low-dose combination ICS-formoterol: this is a combination of ICS and formoterol, a LABA with fast onset of action. It is an anti-inflammatory reliever inhaler that relieves symptoms as quickly (or almost as quickly) as a SABA, and it also provides a low-dose of anti-inflammatory medication to treat the airway inflammation.
In people with mild asthma, low-dose ICS-formoterol can be used as-needed on its own, without any regular daily controller treatment. It reduces the risk of having severe attacks compared with using only a SABA reliever. This as-needed-only treatment is approved for mild asthma in many (but not all) countries.
For patients with moderate or severe asthma, ICS-formoterol is taken both as the person’s regular daily maintenance treatment and they also take it as-needed for symptom relief. This is called Maintenance and Reliever Therapy (MART). It reduces the risk of having severe attacks compared with using a SABA reliever. MART has been approved for treatment of asthma in many countries for many years.
For patients prescribed combination ICS-formoterol, it can also be used before exercise or before allergen exposure.
All adults, adolescents and children aged six years and older should be prescribed an ICS-containing inhaler, to reduce the risk of severe attacks. Asthma should not be treated with a SABA reliever alone, except in some young children.
Other medications
Oral corticosteroids (OCS): Similar to ICS, oral corticosteroids reduce the inflammation in the lungs, but they are used only in case of severe attacks because they can have many serious side effects. They are sometimes considered for patients with severe untreatable asthma but only as a last option.
Leukotriene receptor antagonists (LTRA): Anti-inflammatory drugs that can be used in mild asthma, but are less effective than ICS. These medications are also associated with an increased risk of serious mental health and behaviour changes including in children; discuss this with your doctor. In 2020 the Food and Drug Administration required a warning about serious mental health side effects for asthma and allergy drug Montelukast.
Biological therapies (for severe asthma): Biological therapies are used for patients whose asthma is not responding to high dose ICS-LABA with good adherence and correct technique. They selectively target the immune system components that are causing the inflammation, so they may not work for everyone. Therefore, it is important to identify the type of asthma before deciding to switch to a biological therapy.
Asthma treatment: step it up, step it down!
Asthma treatment must be continuously monitored and adjusted. After diagnosis, your doctor will suggest an initial treatment. Within two-three months after starting controller treatment, you will need to check with your healthcare provider to see how you are responding to the therapy. Asthma medications may later be “stepped-up” or “stepped-down”, this means that the dose and type of medicines you need may be increased or decreased according to how your body responds to the treatment. It is also important to review the inhaler technique with the help of a healthcare provider to ensure you are getting the right amount of medicine at each inhalation .
If the asthma is well under control, you and your doctor may decide to “step-down” the treatment, also considering the general and environmental conditions. On the other hand, if you are having frequent symptoms or experiencing attacks and if you feel your medication is not helping you to the extent you had imagined despite taking it regularly and with correct technique, it may be necessary to “step-up” the treatment such as increasing the doses or changing the medication, as well as treating any risk factors.
Asthma is a variable condition, and adjustments of treatment may include:
- Day-to-day adjustment if you are prescribed anti-inflammatory reliever inhaler: Know how to adjust the as-needed doses of your anti-inflammatory reliever (budesonide-formoterol or beclometasone-formoterol) according to your symptoms. Ask your doctor how many inhalations you should take, and what is the maximum number of doses in any day if your asthma is worsening.
- Short-term controller step-up (for 1–2 weeks) if your reliever is a SABA: Know when to increase the dose of maintenance ICSs for 1–2 weeks, for example if your asthma is worse during viral infections, seasonal allergy or exposure to allergens.
- Sustained controller step-up (for at least 2–3 months): Know when the treatment prescribed does not succeed in controlling asthma. Unsuccessful control may be due to an individual’s response to treatment, in which case the patient should inform the doctor, who may propose to change or step-up the therapy.
To decide the best treatment for you, or to help your doctor to identify when it is time to change treatment, it can be useful that you keep a daily asthma journal.
Treatment for severe asthma or difficult-to-treat asthma
If you have severe or difficult-to-treat asthma despite high doses of ICS-LABA, correct inhaler technique and good adherence to treatment, your healthcare provider will review other factors that may be contributing to poor asthma control.
They may also consider new treatment options or add-ons to therapy that target specific mechanisms of inflammation that cannot be controlled with standard treatment. In order to understand if some add-on treatments may be beneficial for you, the specialist will examine your clinical history and may ask for further exams to identify if you have a specific type of asthma that may respond to these treatments. The goal is to improve control of symptoms, reduce the risk of severe exacerbations, and minimise the use of oral corticosteroids that have many serious long-term side effects.
Side effects of medications
Asthma medications should be taken only after medical consultation . It is very important that you carefully follow the doctor’s indications about the dose you should take and that you acquire a good inhaler technique.
Use of oral corticosteroids once a year or more increases the risk of side effects, such as easy bruising, increased risk of osteoporosis, diabetes, heart failure, cataracts and glaucoma. Use of high dose ICS for long periods may increase the risk of osteoporosis and cataract. They may also increase local side effects, such as oral thrush and hoarse voice. The risk of oral thrush can be reduced by rinsing the mouth and spitting out after taking the inhaler.
Any adverse event you experience should be reported. Discuss any adverse event you may experience with doctor and to the pharmacist. Reporting suspected side affects you can help the authorities in their investigations, which will lead to safer medicines.
Optimise your asthma inhaler technique
Inhalers are complex drug-device combinations and patients need training about how to use them. Using your inhaler correctly is essential to ensure that your lungs receive the amount of medicine you need at each puff. An incorrect inhaler technique leads to poor asthma control, increased risk of severe asthma attacks and more adverse effects.
Four main steps to follow to use your inhaler correctly :
- CHOOSE
- Your healthcare provider will help you choose the inhaler device that best suits your needs, taking into account the asthma medication(s) you need, which of the available devices you can use easily and correctly, and their environmental impact.
- Ensure that you can easily use the inhaler and that you are not limited by such other factors as arthritis.
- For pressurised metered dose inhalers (pMDI), the use of a spacer improves delivery and reduces the potential for side effects.
- If you need two different medications for your asthma, e.g., a separate reliever and controller, it is best to have the same type of inhaler device for each, if possible, to reduce confusion about the technique.
- CHECK
- Ask your healthcare provider to demonstrate how to use the device correctly.
- Watch videos online to see how to use your inhaler.
- Check your inhaler technique with your healthcare provider at every opportunity. Show them how you are actually using the inhaler.
- CORRECT
- Check your technique repeatedly, and pay attention to the steps you are less comfortable with.
- Re-check your inhaler technique frequently. By 4–6 weeks after initial training, many people will no longer have correct technique with their inhaler, so training has to be repeated frequently.
- Electronic inhaler monitoring and reminders may improve adherence.
- CONFIRM
- Don’t be shy to ask your healthcare provider to give you a demonstration of the technique, especially if your device is changed.
Pharmacists and nurses are great allies if you want to review your inhaler technique .
- Don’t be shy to ask your healthcare provider to give you a demonstration of the technique, especially if your device is changed.
How to use your inhaler safely
Rinse out your mouth after inhaling an inhaled corticosteroid-containing medication, whenever convenient (e.g., at home in the morning or evening). This helps to prevent the risk of fungal infection. Nevertheless, if rinsing out your mouth is not possible or not convenient, for instance you use the inhaler when you are out, don’t worry since the risk of infection is very small.
Dispose the canister
Expired or empty canisters should not be thrown in the rubbish bin. Check with your pharmacist the correct way to dispose of them.
About your asthma inhaler
Pressurised metered dose inhaler (pMDI): a pressurised canister of medicine in a plastic holder with a mouthpiece. When sprayed and inhaled correctly with a slow inhalation, it gives a reliable, consistent dose of medication. The propellant in current pMDIs has a much higher potential contribution to global warming than dry powder inhalers, but new propellants are being developed. Controller medications delivered by pMDIs should normally be used with a spacer.
Spacer: also known as “holding chamber” is an attachment used with a pMDI that keeps the medicine in place so that you can more easily breathe it in. The use of a spacer improves delivery of the medication and reduces potential side effects.
Dry powder inhaler (DPI): many asthma medications are available as a powder that is inhaled into the lungs. Check the correct technique for loading a dose and inhaling the medication for each type of DPI. For most DPIs, a strong breath in is needed.
Mist inhaler: a small number of medications are available in an inhaler that dispenses the medication as a fine mist.
Nebuliser: a piece of medical equipment that turns liquid medicine into a very fine mist to be inhaled through a face mask or mouthpiece. These are rarely needed except in the emergency department for treatment of life-threatening asthma.
Manufacturers usually provide patient resources to show how the inhaler should be used, and there are websites with good demonstration videos. Ask your doctor and pharmacist for online resources in your language.