Pharmacologic Treatment of Asthma
Medication | Comments |
|---|---|
Short-acting beta agonists | |
AlbuterolAlbuterol | Albuterol is used as a reliever* medication. It is not recommended for maintenance treatment. Regular use indicates diminishing asthma control and need for an additional medication. MDI-DPI is as effective as nebulized therapy if patients can coordinate the inhalation maneuver using the spacer and holding chamber. Nebulized albuterol can be mixed with other nebulizer solutions. |
LevalbuterolLevalbuterol | Levalbuterol is the R-isomer of albuterol. Levalbuterol may have fewer adverse effects. |
Long-acting beta agonists (not to be used as monotherapy) | |
ArformoterolArformoterol | Arformoterol is the R-isomer of formoterol. |
FormoterolFormoterol | — |
SalmeterolSalmeterol | Duration of action is 12 hours. One dose nightly is helpful for nocturnal asthma. Salmeterol is not to be used for acute symptom relief in an exacerbation. |
Ultra–long-acting beta agonists (not to be used as monotherapy) | |
Indacaterol | — |
OlodaterolOlodaterol | — |
Vilanterol | Vilanterol is available only in combination with fluticasone and/or umeclidinium. |
Anticholinergics | |
IpratropiumIpratropium | Ipratropium may be mixed in the same nebulizer as albuterol. It should not be used as first-line therapy. Regular use provides no clear benefit for long-term maintenance therapy but should be added for treatment of acute symptoms. |
TiotropiumTiotropium | Tiotropium is longer acting than ipratropium. The lower dose SMI tiotropium is the only dose recommended for use in asthma.The lower dose SMI tiotropium is the only dose recommended for use in asthma. |
Glucocorticoids (inhaled) | |
BeclomethasoneBeclomethasone | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
BudesonideBudesonide | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
CiclesonideCiclesonide | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
FlunisolideFlunisolide | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
Fluticasone furoateFluticasone furoate | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
Fluticasone propionateFluticasone propionate | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
MometasoneMometasone | Doses depend on severity and range from 1–2 puffs to whatever dose is needed to control asthma. May have systemic effects when used long term. Maximum threshold is that above which hypothalamic- pituitary-adrenal suppression is produced. If higher doses are necessary for asthma control, specialist consultation is recommended. |
Systemic glucocorticoids (oral) | |
MethylprednisoloneMethylprednisolone | Maintenance doses should be given in a single dose in the morning every day or every other day as needed for control. Short-course burst doses are effective for establishing control when initiating therapy or during a period of gradual deterioration. The burst should be continued until PEF = 80% of personal best or symptoms resolve, possibly requiring > 3–10 days of therapy. |
PrednisolonePrednisolone | Maintenance doses should be given in a single dose in the morning every day or every other day as needed for control. Short-course burst doses are effective for establishing control when initiating therapy or during a period of gradual deterioration. The burst should be continued until PEF = 80% of personal best or symptoms resolve, possibly requiring > 3–10 days of therapy. |
PrednisonePrednisone | Maintenance doses should be given in a single dose in the morning every day or every other day as needed for control. Short-course burst doses are effective for establishing control when initiating therapy or during a period of gradual deterioration. The burst should be continued until PEF = 80% of personal best or symptoms resolve, possibly requiring > 3–10 days of therapy. |
Combination medications | |
Ipratropium/albuterolIpratropium/albuterol | Ipratroprium prolongs bronchodilator effect of albuterol. |
Fluticasone/salmeterolFluticasone/salmeterol | The medium-dose inhaler is indicated for asthma not controlled by low-to-medium doses of inhaled glucocorticoids. The high-dose is indicated for asthma not controlled by medium-to-high doses of inhaled glucocorticoids. |
Budesonide/formoterolBudesonide/formoterol | The lower dose inhaler is indicated for asthma not controlled by low-to-medium doses of inhaled glucocorticoids. The higher dose inhaler is indicated for asthma not controlled by medium-to-high doses of inhaled glucocorticoids. |
Mometasone/formoterolMometasone/formoterol | The low-dose combination is recommended for asthma not controlled by low-dose glucocorticoids alone. The medium-dose combination is recommended for asthma not controlled by medium–dose inhaled glucocorticoids. The high-dose combination is recommended for asthma not controlled by high-dose inhaled glucocorticoids. |
Fluticasone/vilanterolFluticasone/vilanterol | Recommended starting dose is based on asthma severity. |
Fluticasone/umeclidinium/vilanterolFluticasone/umeclidinium/vilanterol | Recommended starting dose is based on asthma severity. |
Budesonide/ albuterolBudesonide/ albuterol | Budesonide/albuterol is used as reliever therapy. |
Mast cell stabilizers | |
CromolynCromolyn | Cromolyn (nebulized) should be taken before exercise or allergen exposure. One dose provides effective prophylaxis for 1–2 hours. |
NedocromilNedocromil | Nedocromil is available as adjunct maintenance therapy for mild-to-moderate persistent asthma. Nedocromil is available as adjunct maintenance therapy for mild-to-moderate persistent asthma. It is less effective than inhaled glucocorticoids. |
Leukotriene modifiers | |
MontelukastMontelukast | Montelukast is a leukotriene receptor antagonist that is a competitive inhibitor of leukotrienes D4 and E4. Caution must be exercised before initiating montelukast due to the potential risk of neuropsychiatric adverse drug events. |
ZafirlukastZafirlukast | Zafirlukast is a leukotriene receptor antagonist that is a competitive inhibitor of leukotrienes D4 and E4. It must be taken 1 hour before or 2 hours after meals. |
ZileutonZileuton | Zileuton inhibits 5-lipoxygenase. Dosing may limit adherence. Zileuton may cause liver enzyme elevations and inhibit metabolism of drugs processed by CYP3A4, including theophylline. may cause liver enzyme elevations and inhibit metabolism of drugs processed by CYP3A4, including theophylline. Zileuton can be used in children, but only in those ≥ 12 years. |
Methylxanthines | |
TheophyllineTheophylline | The wide variability in metabolic clearance, drug interaction, drug-induced relaxation of the lower esophageal sphincter worsening reflux and worsening bronchospasm, and potential for adverse effects mandate routine serum level monitoring. Availability of safer alternatives has led to declining use of this medication. |
Biologics | |
BenralizumabBenralizumab | Benralizumab is used as an add-on treatment for patients with the eosinophilic phenotype. |
DupilumabDupilumab | The initial (loading) dose should be given as 2 injections. Dupilumab is used as an add-on treatment for patients with the eosinophilic phenotype. |
MepolizumabMepolizumab | — |
Omalizumab or biosimilar (Omalizumab or biosimilar (omalizumab-igec) | — |
ReslizumabReslizumab | — |
TezepelumabTezepelumab | Tezepelumab is an add-on treatment for patients with severe, persistent asthma. |
* Relievers, also called rescue inhalers, include a short-acting beta-2-agonist, an inhaled glucocorticoid plus a short-acting beta-2-agonist, or an inhaled glucocorticoid plus a long-acting beta-2-agonist. | |
DPI = dry-powder inhaler; MDI = metered-dose inhaler; SMI = soft mist inhaler; PEF = peak expiratory flow. | |
Adapted from the National Heart, Lung, and Blood Institute: Expert Panel Report 3, Guidelines for the diagnosis and management of asthma—full report 2007. August 28, 2007. Available at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf; and Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 146(6):1217–1270, 2020. doi: 10.1016/j.jaci.2020.10.003 | |
For additional information, see Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated May 2025. Accessed May 20, 2025. Available from www.ginasthma.org | |