Medications for Chronic Asthma

 


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Chronic asthma is a major health concern for children and adults worldwide. The goal of treatment is to prevent symptoms by reducing airway inflammation and hyperreactivity. Step-up therapy for symptom control involves initiation with low-dose treatment and increasing intensity at subsequent visits if control is not achieved. Step-down therapy starts with a high-dose regimen, reducing intensity as control is achieved. Multiple randomized controlled trials have shown that inhaled corticosteroids are the most effective monotherapy. Other agents may be added to inhaled corticosteroids if optimal symptom control is not initially attained. Long-acting beta2 agonists are the most effective addition, but they are not recommended as monotherapy because of questions regarding their safety. Leukotriene receptor antagonists can be used in addition to inhaled corticosteroids, but they are not as effective as adding a long-acting beta2 agonist. Patients with mild persistent asthma who prefer not to use inhaled corticosteroids may use leukotriene receptor antagonists as monotherapy, but they are less effective. Because of their high cost and a risk of anaphylaxis, monoclonal antibodies should be reserved for patients with severe symptoms not controlled by other agents. Immunotherapy should be considered in persons with asthma triggered by confirmed allergies if they are experiencing adverse effects with medication or have other comorbid allergic conditions. Many patients with asthma use complementary and alternative agents, most of which lack data regarding their safety or effectiveness.

Approximately 25.7 million persons in the United States, including 7 million children, had the diagnosis of asthma as of 2010.1 It is reported that 4.1 million children experienced at least one asthma exacerbation in 2011.2 Between 1995 and 2010, exacerbations accounted for one-third of all hospital admissions for children younger than 15 years.3 Asthma caused 3,345 U.S. deaths in 2011,4 and it accounts for $50.1 billion annually in direct health care costs.5 The management of asthma involves care plans, chronic medications, and monitoring and self-care for acute exacerbations. Therapeutic agents used in the chronic management of asthma aim to prevent symptoms by controlling airway inflammation and hyperreactivity. This article reviews the currently available medications and complementary agents for chronic asthma management. A previous article in American Family Physician discussed the management of acute exacerbations.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Inhaled corticosteroids improve asthma control and quality of life and reduce asthma symptom severity, systemic steroid use, emergency department visits and hospitalizations, and deaths.

A

10, 1518

Long-acting beta2 agonists are effective for control of persistent asthma symptoms and are the preferred agents to add to inhaled corticosteroids in patients 12 years and older, but they are not recommended for use as monotherapy.

A

10, 27, 29

Leukotriene receptor antagonists can be used as adjunctive therapy with inhaled corticosteroids, but they are less effective than long-acting beta2 agonists in patients 12 years and older.

B

10, 15, 26

If adequate symptom control is not attained with low-dose inhaled corticosteroids, either increasing the inhaled steroid dosage or adding a long-acting beta2 agonist to therapy is appropriate according to current guideline recommendations.

B

10, 30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Inhaled corticosteroids improve asthma control and quality of life and reduce asthma symptom severity, systemic steroid use, emergency department visits and hospitalizations, and deaths.

A

10, 1518

Long-acting beta2 agonists are effective for control of persistent asthma symptoms and are the preferred agents to add to inhaled corticosteroids in patients 12 years and older, but they are not recommended for use as monotherapy.

A

10, 27, 29

Leukotriene receptor antagonists can be used as adjunctive therapy with inhaled corticosteroids, but they are less effective than long-acting beta2 agonists in patients 12 years and older.

B

10, 15, 26

If adequate symptom control is not attained with low-dose inhaled corticosteroids, either increasing the inhaled steroid dosage or adding a long-acting beta2 agonist to therapy is appropriate according to current guideline recommendations.

B

10, 30


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For in

The Authors

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NATHAN P. FALK, MD, is a faculty physician at Florida Hospital Family Medicine Residency, Winter Park. At the time this article was written, Dr. Falk was director of Primary Care Sports Medicine at Offutt Air Force Base, Neb....

SCOTT W. HUGHES, MD, is clinical faculty at the Offutt Air Force Base Family Medicine Residency.

BLAKE C. RODGERS, MD, is clinical faculty at the Offutt Air Force Base Family Medicine Residency.

Address correspondence to Nathan P. Falk, MD, 133 Benmore Dr., Suite 201, Winter Park, FL 32792 (e-mail: Nathan.Falk.MD@flhosp.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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