These medications are taken on a regular basis to prevent asthma attacks and control 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 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. The use of inhaled corticosteroids in patients with moderate-to-severe asthma reduces the rate of rehospitalizations and deaths from asthma.
Receiving corticosteroids using 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, steroids taken by mouth have considerable side effects throughout the body.) Inhaled corticosteroids are recommended as the primary therapy for any patient needing long-term control medications for persistent asthma.
Examples of inhaled corticosteroids:
Optimal timing of the dose is important and may vary depending on the medication.
Inhaled steroids are generally considered safe and effective and only rarely cause any of the more serious side effects reported with prolonged use of oral steroids. The following are side effects of inhaled steroids:
Long-acting beta2-agonists are are used for preventing an asthma attack (not for treating attack symptoms). These drugs 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. In 2008, an FDA advisory panel voted to ban the use of salmeterol (Serevent) and formoterol (Foradil) for treatment of asthma in children and adults. The FDA panel decided that salmeterol-fluticasone (Advair) and formoterol-budesonide (Symbicort), long-acting beta2 agonists products that are combined with a steroid in a single inhaler, can continue to be used for treatment of moderate-to-severe asthma.
Doctors are still trying to determine when long-acting beta2-agonists should be added to an asthma treatment plan. If your symptoms do not improve or if symptoms worsen with this type of drug, your doctor will recommend discontinuing it. Do not, however, stop taking this drug or other asthma medications without first talking with your doctor.
Cromolyn sodium (Intal) is both an anti-inflammatory drug and has antihistamine properties that block asthma triggers, such as allergens, cold, or exercise. A cromolyn nasal spray called NasalCrom has been approved for over-the-counter purchase, but only to relieve nasal congestion caused by allergies. Patients should not use it for self-medication without the advice of a doctor.
Candidates. Cromolyn is a treatment option for exercise-induced asthma (EIA) in all age groups, for pregnant women, and possibly for preventing allergic asthma in adults as well as children. Cromolyn may be used as an alternative to inhaled corticosteroids, inhaled corticosteroids are considered the preferred choice for long-term control of persistent asthma.
Side Effects. Side effects of cromolyn include nasal congestion, coughing, sneezing, wheezing, nausea, nosebleeds, and dry throat.
Leukotriene antagonists (also called anti-leukotrienes or leukotriene modifiers) are pills that block leukotrienes. Leukotrienes are powerful immune system factors that, in excess, produce a battery of damaging chemicals that can cause inflammation and spasms in the airways of people with asthma. As with other anti-inflammatory drugs, leukotrienes are used for prevention, NOT for treating acute asthma attacks.
Leukotriene antagonists include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo). These drugs are considered an alternative for long-term control of asthma, but inhaled corticosteroids should always be used first. Other potential uses include preventing exercise-induced asthma.
Side Effects and Complications. Gastrointestinal distress is the most common side effect of leukotriene antagonists. Other concerns are indications of liver injury in patients when taking zafirlukast at higher than standard doses. No adverse effects on the liver have been reported to date with montelukast.
The FDA is evaluating reports of suicidal tendencies associated with these medications. Patients who take a leukotriene antagonist drug should be monitored for signs of behavioral and mood changes.
Theophylline. Theophylline (Theo-Dur, Theolair, Slo-Phyllin, Slo-bid, Constant-T, and Respbid) relaxes the muscles around the bronchioles and also stimulates breathing. The use of inhaled corticosteroids and long-acting beta2-agonists has dramatically reduced the need to use theophylline in most patients with asthma. It may be useful for treating nocturnal asthma. Available in tablet, liquid, and injectable forms, some theophylline sustained-release tablets and capsules work for a long time and can, therefore, be taken once or twice a day with good results.
If theophylline is not taken exactly as prescribed, an overdose can easily occur. Toxicity can cause nausea, vomiting, headache, insomnia, and, in rare cases, disturbances in heart rhythm and convulsions. Contact a doctor immediately if any of these side effects occur.
The risks for these adverse effects are small if the drug is taken exactly as prescribed, but patients should note the following precautions:
Omalizumab (Xolair) is FDA-approved for patients age 12 and older who have moderate-to-severe persistent asthma related to allergies. The presence of allergies must generally be proven by increased levels in the blood of a certain antibody called immunoglobulin E (IgE). The first drug of this type to be approved for asthma, omalizumab is a monoclonal antibody (MAb), a genetically developed drug designed to attack very specific targets. Omalizumab is given by injection every 2 - 4 weeks. It is used only to treat patients who have moderate-to-severe persistent asthma related to allergies whose symptoms are not controlled by inhaled corticosteroids.
Omalizumab prevents IgE from triggering the inflammatory events that lead to asthmatic attacks. Studies have shown excellent benefits of the drug, including a reduced need for corticosteroids, fewer hospitalizations, and significant symptomatic improvements.
However, 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:
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