Patients need to take an active role in controlling their asthma. This brochure discusses the steps to making an asthma action plan, and some of the medications used to control asthma symptoms.
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FOR CARE TEAMS
Treating Asthma and Severe Asthma
Patients need to take an active role in controlling their asthma. There is no cure for asthma, but by working together, patients and healthcare providers can help avoid asthma attacks and make living with the condition easier.1
This flashcard outlines the different treatments healthcare providers use to help patients manage their symptoms.
Creating an Asthma Action Plan
Taking an active role in asthma management means patients and healthcare providers should be partners and work together to create an action plan that will1,2:
*Physical activity plays an important role in being healthy. If a patient's asthma is triggered by exercise, treatment should be adjusted to minimize risks.1
Categories of Asthma Medications
The pharmacological options for long-term treatment of asthma fall into 3 main categories3:
Controller medications are used for regular maintenance treatment. They reduce airway inflammation, control symptoms, and reduce future risks such as exacerbations and decline in lung function.3
Reliever (rescue) medications are provided to all patients for as-needed relief from symptoms that occur despite the use of controller medication. They are also recommended for short-term prevention of exercise-induced asthma. Reducing and, ideally, eliminating the need for reliever treatment is both an important goal in asthma management and a measure of the success of asthma treatment.3
Add-on therapies for patients with severe asthma may be considered when patients have persistent symptoms and/or exacerbations despite optimized treatment with high-dose controller medications and treatment of modifiable risk factors.3
Inhaled Corticosteroids (ICS)
ICSs are usually the first line of defense in patients with asthma who need a controller medication. An ICS may be combined with other medications if symptoms are not controlled. These anti-inflammatory medicines reduce swelling and mucus production in the airways, making it easier for the patient to breathe. Corticosteroids used for asthma are usually inhaled. When taken long-term, they may have side effects such as cataracts and osteoporosis. It is important to instruct patients to rinse their mouth with water immediately after using an ICS to avoid getting oral thrush, a yeast infection in the throat that is associated with ICS use.1,3,4
Corticosteroids also come in pill form (oral corticosteroids, or OCS) and may be used for short periods of time, such as when asthma symptomsare exacerbated.3,4
These drugs contain 2 different types of medication, usually an inhaled bronchodilator and an inhaled corticosteroid, together in the same inhaler device. They can also contain 2 different types of inhaled bronchodilators for the treatment of COPD.3-5
These medicines improve lung function. They act by relaxing the muscles in the airways so that the airways open up and the patient can breathe better. They may also improve exercise performance.3,5
There are 2 main types of bronchodilators used in asthma treatment:
Beta2-agonists relax airway muscles. Short-acting beta2-agonists (SABAs) last for about 4 to 6 hours and are often used only when needed for quick relief. They can also be taken before exercising to prevent exercise-induced asthma. If asthma is controlled, patients should not be using their SABA more than twice a week. If a patient needs to take a SABA more frequently, it may be a sign that his or her asthma is not well controlled. Long-acting beta2-agonists (LABAs) last for about 12 hours or more. LABAs should be taken only in combination with an ICS to treat asthma5,6
Anticholinergics are another type of bronchodilator that enlarges (dilates) the airways in the lungs, making breathing easier. They also may reduce the amount of mucus blocking the airways. A long-acting anticholinergic may be given in cases of severe asthma7
Theophylline is a potential alternative to SABAs for relief of asthma symptoms in adults. Theophylline is not recommended for routine use as it has a slower onset of action than an inhaled SABA and a higher risk of side effects than inhaled SABAs.3
Healthcare providers may also opt for a different treatment regimen utilizing the medications below as an add-on to current therapies.3
Leukotriene receptor antagonists (LTRA). These medications are also taken by mouth and help block the chain reaction that increases inflammation in the airways. They are used both for treatment and prevention of acute asthmatic attacks1,8
Anti-IgE antibodies. This is a class of biologics* usually given by injection or infusion once or twice a month by a healthcare provider. It helps prevent an allergic patient from reacting to asthma triggers. It is added on to already-prescribed asthma medications3,9
Anti-IL-5 antibodies. This is a class of biologics given by injection or infusion that may help ease inflammation in some patients with severe eosinophilic asthma. It is added on to already-prescribed asthma medications3,10
*A biologic is a type of drug consisting of natural components such as sugars, proteins, cells, and tissues, as opposed to a drug that is chemically synthesized.11
Treating Eosinophilic Asthma3,12,13
If you determine, with the help of a simple blood test, that a patient with severe asthma has eosinophilic asthma, there are treatment options designed to address it. These treatments are available either as an injection or an IV and should be added on to existing asthma treatment regimens.
Stepwise Approach to Asthma Control3
The Global Initiative for Asthma (GINA) is a collaboration of the National Heart, Lung, and Blood Institute and the World Health Organization. GINA is made up of a network of individuals, organizations, and public health officials that disseminates information about the care of patients with asthma. GINA also provides a mechanism to translate scientific evidence into improved asthma care. The GINA report on asthma care has been updated every year since 2002. Its current therapeutic recommendations for controlling asthma symptoms and minimizing future risk are divided into 5 steps that address asthma progressively, from mild to severe:
Step 1: No preferred controller choice. A controller option is to consider a low-dose ICS. SABAs should be used as needed, for quick relief of asthma symptoms.
Step 2: The preferred controller choice is a low-dose ICS. Two other controller options are LTRAs and low-dose theophylline. A SABA is recommended for relief as needed
Step 3: The preferred controller is a combination of a low-dose ICS and a LABA. Two other controller options are a medium- to high-dose ICS, or a low-dose ICS plus an LTRA or theophylline. A SABA or other medications can be used as needed for relief.
Step 4: The preferred controller is a medium- to high-dose ICS/LABA combination. Options include adding on an anticholinergic, a high-dose ICS plus an LTRA, or a high-dose ICS plus theophylline. A SABA or other medications can be used as needed for relief.
Step 5: For preferred control, GINA recommends an add-on treatment such as an anticholinergic or an anti-IgE or anti-IL5 biologic. Another option is to add on a low-dose OCS. A SABA or other medications can be used as needed for relief.
Patients can be stepped down if their asthma begins to improve or stepped up if their symptoms worsen.
References: 1. National Heart, Lung, and Blood Institute. Asthma Care Quick Reference. https://www.nhlbi.nih.gov/sites/default/files/media/docs/asthma_qrg_0_0.pdf. Accessed January 11, 2018. 2. Asthma Initiative of Michigan. How to use your peak flow meter. https://getasthmahelp.org/peak-flow-how-to.aspx. Accessed November 21, 2017. 3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2017. https://ginasthma.org/2017-gina-report-global-strategy-for-asthma-management-and-prevention/. Accessed November 15, 2017. 4. American Lung Association. Understand your medication. https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/understand-your-medication.html. Accessed November 21, 2017. 5. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2017 report). https://www.sppneumologia.pt/uploads/files/comissoestrabalho/Fisiopatologia%20e%20DPOC/wms-GOLD-2017-FINAL.pdf. Accessed November 15, 2017. 6. American Academy of Allergy, Asthma and Immunology. Beta2-agonists (bronchodilators). https://www.aaaai.org/conditions-and-treatments/conditions-dictionary/beta2-agonists-(bronchodilators). Accessed November 21, 2017. 7. American College of Allergy, Asthma and Immunology. Asthma treatment. https://acaai.org/asthma/asthma-treatment. Accessed November 21, 2017. 8. National Institute of Diabetes and Digestive and Kidney Diseases. Overview: leukotriene receptor antagonists. https://livertox.nih.gov/LeukotrieneReceptorAntagonists.htm. Accessed November 24, 2017. 9. National Jewish Health Organization. Anti-IgE treatment. https://www.nationaljewish.org/treatment-programs/medications/asthma-medications/longterm/anti-ige-treatment. Accessed November 21, 2017. 10. Mukherjee M, Sehmi R, Nair P. Anti-IL5 therapy for asthma and beyond. World Allergy Organ J. 2014;7(1):32. 11. U.S. Food and Drug Administration. What are "biologics" questions and answers. https://www.fda.gov/aboutfda/centersoffices/officeofmedicalproductsandtobacco/cber/ucm133077.htm. Accessed November 21, 2017. 12. Tefferi A, Hanson CA, Inwards DJ, et al. How to interpret and pursue an abnormal complete blood cell count in adults. Mayo Clin Proc. 2005;80(7):923-936. 13. National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and management of asthma. https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Accessed November 21, 2017.