In asthma, the airways narrow—usually reversibly—in response to certain triggers. Medications allow most people with asthma to lead relatively normal lives. Most of the medications used to treat an asthma attack (exacerbation) can be used (often in lower doses) to prevent attacks.
Therapy is based on 2 classes of medications:
Anti-inflammatory medications
Bronchodilators
Anti-inflammatory medications suppress the inflammation that narrows the airways. Anti-inflammatory drugs include steroids (sometimes called glucocorticoids or corticosteroids), leukotriene modifiers, and mast cell stabilizers. Steroids can be inhaled, taken by mouth, or given intravenously. Leukotriene modifiers are taken by mouth. Mast cell stabilizers given for asthma are inhaled.
Bronchodilators help to relax and widen (dilate) the airways. Bronchodilators include beta-adrenergic medications (both those for quick relief of symptoms and those for long-term control), anticholinergics, and methylxanthines. They are typically inhaled.
Other types of medications that directly alter the immune system (called immunomodulators) are sometimes used for people with severe asthma, but most people do not need immunomodulators.
Beta-Adrenergic Medications
Short-acting beta-adrenergic medications
Short-acting beta-adrenergic medications may be used for relieving asthma attacks. They also are used to prevent exercise-induced bronchoconstriction. These medications are referred to as bronchodilators because they stimulate beta-adrenergic receptors to widen (dilate) the airways. Bronchodilators that act on all beta-adrenergic receptors throughout the body (such as epinephrine) cause side effects such as rapid heartbeat, restlessness, headache, and muscle tremors. Bronchodilators (such as albuterol) that act mainly on beta-2-adrenergic receptors, which are found primarily on cells in the lungs, have less effect on other organs and thus cause fewer side effects. Most short-acting beta-adrenergic medications, especially the inhaled ones, act within minutes, but the effects last only 6 to 8 hours.) cause side effects such as rapid heartbeat, restlessness, headache, and muscle tremors. Bronchodilators (such as albuterol) that act mainly on beta-2-adrenergic receptors, which are found primarily on cells in the lungs, have less effect on other organs and thus cause fewer side effects. Most short-acting beta-adrenergic medications, especially the inhaled ones, act within minutes, but the effects last only 6 to 8 hours.
Quick medical attention should be sought when a person who has asthma feels the need to use more of a beta-adrenergic medication than is recommended. The need for extra use, particularly continuous use, indicates worsening bronchoconstriction, which can be dangerous, possibly risking even respiratory failure and death.
Long-acting beta-adrenergic medications
Long-acting beta-adrenergic medications (such as formoterol) may be used for relieving as well as preventing asthma attacks, when used along with an inhaled steroid. Long-acting beta-adrenergic drugs are effective for about 12 hours, so people usually need 2 doses per day. Long-acting beta-adrenergic medications (such as formoterol) may be used for relieving as well as preventing asthma attacks, when used along with an inhaled steroid. Long-acting beta-adrenergic drugs are effective for about 12 hours, so people usually need 2 doses per day.
The long-acting beta-adrenergic medications are not recommended to be used alone; doctors always give them together with inhaled steroids.
Ultra–long-acting beta-adrenergic medications
Ultra–long-acting beta-adrenergic medications are effective for up to 24 hours, so people need only one dose per day.
Ultra–long-acting beta-adrenergic medications are also not recommended to be used alone; doctors always give them together with inhaled steroids.
Taking inhaled beta-adrenergic medications
Metered-dose inhalers (handheld cartridges containing gas under pressure) are the most commonly used method for giving inhaled beta-adrenergic medications. The pressure turns the medication into a fine spray containing a measured dose of medication. Inhalation deposits the medication directly in the airways, so that it acts quickly, but the medication may not reach airways that are severely narrowed. Spacers or holding chambers are recommended to be used with any inhaled medication. These devices increase the amount of medication delivered to the lungs. With any type of inhaler, proper technique is vital. If the device is not used properly, the medication will not reach the airways.
A dry powder medication formulation is also available for many bronchodilators. The powder formulation is easier for some people to use, in part because it requires less coordination with breathing than when using a metered-dose inhaler.
How to Use a Metered-Dose Inhaler With a Spacer
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How to Use a Metered-Dose Inhaler
To use a metered-dose inhaler, the person shakes the inhaler and removes the cap. The person exhales completely, then brings the inhaler close to or in the mouth and breathes in slowly while pressing the top of the inhaler. The person continues to inhale as a puff of medicine sprays out. The person then holds the breath and subsequently exhales again. Exhaling fully helps clear air from the lungs, so that more air can be inspired with the next inhalation. The more air is inhaled, the more of the medication can also be inhaled and thus reach the more distant, smaller airways. See the Centers for Disease Control and Prevention: Self-Care for Asthma: Using Your Inhaler. |
A nebulizer can be used to deliver beta-adrenergic medications directly to the lungs. A nebulizer uses pressurized air or ultrasonic sound waves to create a continuous mist of medication that is inhaled without having to coordinate dosing with breathing. Nebulizers are often portable, and some units can even be plugged into a power outlet in a car. Nebulizers and metered-dose inhalers often deliver different amounts of medication with a single dose, but both are capable of delivering sufficient amounts of medication to the lungs. Nebulizer therapy is less likely to reach the more distant airways in people who are breathing comfortably and not taking deep breaths, making nebulized therapy less effective than a correctly used metered-dose inhaler or a dry powder formulation.
Other bronchodilators, including the anticholinergic medication ipratropium delivered through a nebulizer, may be combined with beta-adrenergic medications for acute attacks. A combination of ipratropium plus albuterol given in a metered-dose inhaler is also available.Other bronchodilators, including the anticholinergic medication ipratropium delivered through a nebulizer, may be combined with beta-adrenergic medications for acute attacks. A combination of ipratropium plus albuterol given in a metered-dose inhaler is also available.
Other forms of beta-adrenergic medications are also available. Beta-adrenergic medications can be taken in liquid or tablet form or injected. However, the oral drugs tend to work more slowly than the inhaled or injected ones and are more likely to cause side effects so doctors use them less often. Side effects include abnormal heart rhythms, particularly with excessive use.
Anticholinergic Medications
Anticholinergic drugs (also called cholinergic antagonists or antimuscarinics), such as ipratropium and tiotropium, block acetylcholine from causing smooth muscle contraction and from producing excess mucus in the bronchi. These medications are inhaled. These medications further widen (dilate) the airways in people who have already been given beta-adrenergic medications or an inhaled steroid.Anticholinergic drugs (also called cholinergic antagonists or antimuscarinics), such as ipratropium and tiotropium, block acetylcholine from causing smooth muscle contraction and from producing excess mucus in the bronchi. These medications are inhaled. These medications further widen (dilate) the airways in people who have already been given beta-adrenergic medications or an inhaled steroid.
Leukotriene Modifiers
Leukotriene modifiers, such as montelukast, zafirlukast, and zileuton, also help control asthma. They are anti-inflammatory medications that prevent the action or synthesis of leukotrienes. Leukotrienes are chemicals made by the body that cause bronchoconstriction. These medications, which are taken by mouth, are used more to prevent asthma attacks than to treat them.Leukotriene modifiers, such as montelukast, zafirlukast, and zileuton, also help control asthma. They are anti-inflammatory medications that prevent the action or synthesis of leukotrienes. Leukotrienes are chemicals made by the body that cause bronchoconstriction. These medications, which are taken by mouth, are used more to prevent asthma attacks than to treat them.
Mast Cell Stabilizers
Mast cell stabilizers,such as cromolyn, are inhaled. These medications are thought to inhibit the release of inflammatory chemicals from mast cells and make the airways less likely to narrow. Thus, they are also anti-inflammatory medications. They are useful for preventing but not treating an attack. Mast cell stabilizers may be helpful for children who have asthma and for people who develop asthma due to exercise. These medications are safe and must be taken regularly even when a person is free of symptoms.Mast cell stabilizers,such as cromolyn, are inhaled. These medications are thought to inhibit the release of inflammatory chemicals from mast cells and make the airways less likely to narrow. Thus, they are also anti-inflammatory medications. They are useful for preventing but not treating an attack. Mast cell stabilizers may be helpful for children who have asthma and for people who develop asthma due to exercise. These medications are safe and must be taken regularly even when a person is free of symptoms.
Steroids
Steroids (sometimes called glucocorticoids or corticosteroids) block the body’s inflammatory response and are exceptionally effective at reducing asthma symptoms. They are one of several types of anti-inflammatory medications and have been an important part of asthma treatment for decades.
Steroids can be taken in several different forms. Often, inhaled versions are best because they deliver the medication directly to the airways and minimize the amount that is absorbed throughout the body. The inhaled form is used to prevent attacks and improve lung function. Inhaled steroids come in several strengths and are generally used twice a day. People should rinse their mouth after use to decrease the likelihood that a fungal infection of the mouth (thrush) develops.
Oral or injected steroids may be used in high doses to relieve a severe asthma attack and are generally continued for up to 2 weeks. Oral steroids may be given for several days after an asthma attack and are prescribed on a long-term basis only when no other treatments can control the symptoms.
If taken for long periods, steroids gradually reduce the likelihood of an asthma attack by making the airways less sensitive to a number of provocative stimuli. Long-term use of steroids, especially larger doses taken by mouth, can cause side effects including obesity, osteoporosis, cataracts, easy bruising, skin thinning, insomnia, elevated blood glucose levels, and, very rarely, psychosis. Some studies have suggested that growth may be delayed when children use steroids for an extended period. However, most children who use inhaled steroids eventually reach their predicted adult height.
Biologic Medications
There are several different biologic medications available that target specific molecules involved in airway inflammation. Omalizumab is a drug that is an antibody directed against a group of other antibodies called immunoglobulin E (IgE). There are several different biologic medications available that target specific molecules involved in airway inflammation. Omalizumab is a drug that is an antibody directed against a group of other antibodies called immunoglobulin E (IgE).Omalizumab is used in people with asthma who also have severe allergies and high levels of IgE in their blood. Omalizumab prevents IgE from binding to mast cells and thus prevents the release of inflammatory chemicals that can narrow the airways. It can decrease requirements for oral steroids and help relieve symptoms. The medication is injected subcutaneously every 2 to 4 weeks.
Benralizumab, dupilumab, mepolizumab, reslizumab, and tezepelumab are antibodies that target interleukins or cytokines. They are used in the treatment of people with severe asthma triggered by allergens. Benralizumab, dupilumab, mepolizumab, reslizumab, and tezepelumab are antibodies that target interleukins or cytokines. They are used in the treatment of people with severe asthma triggered by allergens.Mepolizumab reduces the number of asthma attacks, decreases asthma symptoms, and reduces the need for steroids. Mepolizumab is injected subcutaneously every 4 weeks. Reslizumab reduces the number of asthma attacks and decreases asthma symptoms. It is given intravenously every 4 weeks. Benralizumab and dupilumab may be given in addition to other asthma medications for people who have a lot of eosinophils (a type of white blood cell) in their bloodstream. Tezepelumab is given in addition to other asthma medications in people who have severe asthma.
Severe allergic reactions (anaphylaxis) sometimes occur after these medications are given; therefore, these medications are given in supervised healthcare settings, such as outpatient clinics or doctor's offices.
Methylxanthines
Theophylline, a methylxanthine, is another medication that causes bronchodilation. It is used rarely. Theophylline, a methylxanthine, is another medication that causes bronchodilation. It is used rarely.Theophylline is usually taken by mouth. Oral theophylline comes in many forms, from short-acting tablets and syrups to longer-acting sustained release capsules and tablets. Theophylline is used mainly for prevention of asthma.
The amount of theophylline in the blood can be measured in a laboratory and must be closely monitored by a doctor. Too little medication in the blood may provide little benefit, and too much medication may cause life-threatening abnormal heart rhythms or seizures. When first taking theophylline, a person who has asthma may feel slightly jittery and may develop headaches. These side effects usually disappear as the body adjusts to the medication. Larger doses may cause a rapid heartbeat, nausea, or palpitations. A person may also experience insomnia, agitation, vomiting, and seizures. Occurrence of these side effects is one of the reasons that theophylline is used less often than other medications.The amount of theophylline in the blood can be measured in a laboratory and must be closely monitored by a doctor. Too little medication in the blood may provide little benefit, and too much medication may cause life-threatening abnormal heart rhythms or seizures. When first taking theophylline, a person who has asthma may feel slightly jittery and may develop headaches. These side effects usually disappear as the body adjusts to the medication. Larger doses may cause a rapid heartbeat, nausea, or palpitations. A person may also experience insomnia, agitation, vomiting, and seizures. Occurrence of these side effects is one of the reasons that theophylline is used less often than other medications.
Some Medications Commonly Used to Treat Asthma
Medication | Some Side Effects | Comments | |
|---|---|---|---|
Anticholinergics* (inhaled) | |||
IpratropiumIpratropium TiotropiumTiotropium | Dry mouth Rapid heart rate | Usually used in combination with a beta-adrenergic medication | |
Short-acting beta-adrenergic medications (inhaled) | |||
AlbuterolAlbuterol LevalbuterolLevalbuterol | Increased heart rate Shakiness | For immediate relief of acute attack Albuterol also available in oral preparationAlbuterol also available in oral preparation | |
Long-acting beta-adrenergic medications (inhaled) | |||
ArformoterolArformoterol FormoterolFormoterol Salmeterol Salmeterol | Increased heart rate Shakiness | For ongoing treatment, not for acute relief Used together with other asthma medications | |
Ultra–long-acting beta-adrenergic medications (inhaled) | |||
IndacaterolIndacaterol OlodaterolOlodaterol Vilanterol | Runny nose and sneezing High blood pressure Cough Headache | Used together with other asthma medications Vilanterol available only in combination with fluticasone or umeclidiniumVilanterol available only in combination with fluticasone or umeclidinium | |
Steroids (inhaled)* | |||
BeclomethasoneBeclomethasone BudesonideBudesonide CiclesonideCiclesonide FlunisolideFlunisolide Fluticasone furoateFluticasone furoate Fluticasone propionateFluticasone propionate MometasoneMometasone | Fungal infection of the mouth (thrush) A change in the voice | Inhaled for prevention (long-term control) of asthma | |
Steroids (oral or injection)* | |||
MethylprednisoloneMethylprednisolone PrednisolonePrednisolone PrednisonePrednisone | Weight gain Elevated blood sugar levels and blood pressure Rarely, psychosis Osteoporosis Cataracts Skin thinning and easy bruising Insomnia | Used for acute asthma attacks and for asthma that cannot be controlled with inhaled therapy | |
Biologic medications (injection)* | |||
BenralizumabBenralizumab DupilumabDupilumab MepolizumabMepolizumab OmalizumabOmalizumab ReslizumabReslizumab Tezepelumab Tezepelumab | Discomfort at the injection site Rarely, anaphylactic reactions | Used in people with severe asthma to decrease the need for oral steroids | |
Leukotriene modifiers (oral) | |||
Montelukast Montelukast Zafirlukast Zafirlukast ZileutonZileuton | Eosinophilic granulomatosis with polyangiitis With zileuton, elevated liver enzymesWith zileuton, elevated liver enzymes | Used more for prevention (long-term control) than for treatment | |
Mast cell stabilizers (inhaled) | |||
CromolynCromolyn Nedocromil | Coughing or wheezing | Useful for preventing attacks, often related to exercise, but not for treatment of an acute attack Nedocromil not available in the United StatesNedocromil not available in the United States | |
Methylxanthine (oral) | |||
Theophylline Theophylline | Increased heart rate Shakiness Stomach upset Seizures (if the blood level is high) Serious heartbeat irregularities (if the blood level is high) | Can be used for prevention and treatment Taken by mouth but can be given intravenously in a hospital | |
* Anticholinergics may also be called antimuscarinics or cholinergic antagonists. Steroids are sometimes called glucocorticods or corticosteroids. Immunomodulators are sometimes called biologic medications. | |||
Other Medications Used to Treat Asthma and Prevent Attacks
Other medications are occasionally used in asthma treatment. These medications may be used in specific circumstances. Magnesium is often given by vein in the emergency department for acute attacks.
People who take inhaled steroids and who have risk factors for osteoporosis, such as older age, family members with osteoporosis, a diet that is low in calcium and vitamin D, or thin build, may need to take calcium and vitamin D supplements and bisphosphonates to try to preserve bone density.
Allergen immunotherapy (desensitization) may be given when symptoms are triggered by allergy.
More Information
The following are some English-language resources that may be useful. Please note that The Manual is not responsible for the content of these resources.
