Patient education: Medicines for asthma (The Basics)

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What do asthma medicines do? — If you or your child has asthma, the medicines the doctor prescribes can:

●Reduce asthma symptoms – This can make daily activities easier.

●Help prevent asthma attacks or stop them if they happen

Which medicines might I need? — Doctors can use different medicines to treat asthma. These include inhalers, liquids, and pills. You might take 1 or more depending on how often you have symptoms and how serious they are. The medicine and amount you take might change over time.

There are 2 main types of asthma medicines:

●Quick-relief medicines can reduce symptoms in 5 to 15 minutes. People use these medicines to treat asthma attacks or asthma flare-ups.

●Long-term controller medicines help keep asthma symptoms from happening. People take these 1 or 2 times a day every day, even if they have no symptoms. When these medicines are working well, you should need quick-relief medicines less than 2 times a week.

Some medicines can work as both types. These are taken once or twice a day as controller medicines. They can also be used for quick relief when needed.

The medicines listed below are the most common types of asthma medicines.

Quick-relief medicines — These are medicines you take to relieve asthma symptoms when they happen.

●Short-acting beta agonists — Short-acting beta agonists (called "SABAs" or "short-acting bronchodilators") are quick-relief medicines. They relax the muscles around the airways (figure 1).

SABAs can help stop an asthma attack. Also, if you have asthma symptoms when you exercise, it can help to use a SABA 5 to 20 minutes before exercise. Some people feel shaky after taking a SABA. If this happens, your doctor or nurse might tell you to use just 1 puff next time. Or they might give you a different medicine.

Some examples of SABAs are albuterol (sample brand names: ProAir HFA, Proventil HFA, Ventolin HFA) and levalbuterol (brand name: Xopenex HFA). "HFA" means the medicine comes in a metered dose inhaler (picture 1). Albuterol also comes in another type of inhaler, called a dry powder inhaler (sample brand name: ProAir RespiClick).

Another kind of SABA, epinephrine, is sold without a prescription. It comes in an inhaler (brand name: Primatene Mist) or as a liquid you breathe in through a small device (brand name: Asthmanefrin). These non-prescription inhalers can cause dangerous side effects, especially if you use too many puffs. Because of this, doctors generally do not recommend them. If you need a SABA inhaler, your doctor will prescribe one at the right dose for you.

Controller medicines — These are medicines you take every day to help prevent asthma symptoms.

●Inhaled steroids – Inhaled steroids reduce inflammation in the airways. They can take a few days to work, so you will not feel the effect right away. They help prevent symptoms and asthma attacks in the future.

Inhaled steroids come in different kinds of inhalers. Your doctor or nurse will show you how to use the inhaler. Each inhaler has its own directions.

The steroids used to treat asthma are not the same as the steroids some athletes take illegally. It is rare for these medicines to cause side effects. The doctor will give the lowest dose that works well. This reduces the chances of any side effects.

Some examples of inhaled steroids are budesonide (brand name: Pulmicort Flexhaler), ciclesonide (brand name: Alvesco), fluticasone (brand names: Flovent, Arnuity, Armonair), and mometasone (brand name: Asmanex Twisthaler).

Some people worry about side effects of steroid inhalers, so they do not use their inhaler or give it to their child. But the truth is that not using a steroid inhaler is much riskier than any side effects it might cause. Inhaled steroids help keep asthma attacks from starting. These attacks can be dangerous and even cause death. Plus, asthma damages the lungs over time. Inhaled steroids can prevent some of that damage.

●Inhaled steroids plus a long-acting beta agonist – Long-acting beta agonists (called "LABAs") relax the muscles around the airways like SABAs do. But the effects last much longer.

Medicines that have a LABA and steroid in 1 inhaler include fluticasone with salmeterol (brand names: Advair Diskus, Advair HFA, AirDuo, Seretide, Wixela), and fluticasone with vilanterol (brand name: Breo Ellipta). Some combination inhalers, including budesonide with formoterol (brand name: Symbicort) and mometasone with formoterol (brand name: Dulera), can also be used for quick relief of asthma symptoms.

You should only use a LABA at the same time as an inhaled steroid medicine. For this reason, it is best to use 1 inhaler that has both medicines. Some LABAs come in an inhaler without the steroid, but you must take them at the same time as a separate steroid inhaler.

●Leukotriene modifiers – Leukotriene modifiers are long-term controller medicines you take in a pill. They reduce inflammation and mucus, and relax the muscles around the airways. These medicines don't work for everyone. They are not as strong as inhaled steroid medicines.

Some examples of leukotriene modifiers are montelukast (brand name: Singulair), zafirlukast (brand name: Accolate), or zileuton (brand name: Zyflo).

●Tiotropium – This is a type of medicine called a long-acting muscarinic agent (or "LAMA"). It comes in an inhaler (brand name: Spiriva Respimat). Tiotropium is more often used to treat a lung disease called "COPD." But it is sometimes used to control asthma symptoms if other medicines have not worked well.

●Combination inhaled steroid and dual bronchodilator – This medicine uses an inhaled steroid as a controller medicine. It is combined with both a LAMA and a LABA. In the US, the only approved combination inhaler of this type is fluticasone-umeclidinium-vilanterol (brand name: Trelegy). A similar medicine, mometasone-glycopyrrolate-indacaterol (brand name: Enerzair) is available in Canada and Europe.

Combined medicines — Some medicines can work as both a controller medicine and a quick-relief medicine. These are taken once or twice a day as controller medicines, but they can also be used for quick relief.

Combined medicines contain:

●A specific LABA, formoterol, which starts working quickly

●An inhaled steroid, either budesonide or mometasone

These combination medicines (brand names: Dulera, Symbicort) can be convenient because you only need to carry 1 inhaler. They also give you more controller medicine when you need it quickly. Your doctor can talk to you about whether this is an option for you. Some insurance plans might not cover this type of treatment.

Medicines for more severe asthma — People with more severe symptoms might get other medicines, too. Your doctor can talk to you about whether any of these might be an option for you. They include:

●Steroids that come in pills – If other asthma medicines do not work well or you have an asthma flare after a cold virus, you might need to take steroid pills for a few days or weeks. Some people with severe asthma take steroid pills for several months or longer, but this is rare. Some examples of steroid pills for asthma are prednisone and methylprednisolone.

●Omalizumab (brand name: Xolair) – You might get this medicine if your asthma is caused by allergies and inhaled steroids do not work well. It comes in a shot.

●Other medicines – These include benralizumab (brand name: Fasenra), dupilumab (brand name: Dupixent), mepolizumab (brand name: Nucala), tezepelumab (brand name: Tezpire), and reslizumab (brand name: Cinqair). You might get 1 of these medicines if your blood tests show a high level of white blood cells called "eosinophils." Benralizumab, dupilumab, mepolizumab, and tezepelumab come in a shot. Reslizumab is given through a thin tube that goes into a vein, called an "IV."

Where can I get more information about asthma medicines? — If you would like more detailed information, including information on the side effects caused by specific medicines, ask your doctor or nurse for information from Lexicomp, available through UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

What else should I know about asthma medicines? — Take all the medicines your doctor prescribes, exactly how you are supposed to take them. Remember, your controller medicines are helping you even if you do not feel them working.

Use your asthma "action plan" if you have one. An action plan is a list of instructions that tells you:

●Which medicines to use every day

●Which ones to take if your symptoms get worse

●When to get help or call for an ambulance

If you do not have an asthma action plan, ask your doctor whether you need one.