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Quick-Relief Medications

Beta2 agonists
When successful, beta2 agonists produce relief almost immediately and may continue doing so for as long as 6 hours; in acute exacerbations, the duration of effect is often less than 6 hours. Short-acting beta2 agonists (e.g., albuterol, terbutaline) can be delivered either by inhalation or orally. Generally, the inhaled form of delivery is preferred because it is less likely to produce side effects than oral preparations. Injectable beta2 agonists, such as epinephrine (Epipen), are rarely used except in severe circumstances.

Anticholinergics
The inhaled anticholinergics presently are limited to ipratropium bromide (Atrovent). This medication does not modify reactions to allergens, nor does it prevent exercise-induced bronchospasm. Ipratropium bromide can be used as an alternative for patients intolerant to beta2 agonists, but it is not the drug of choice for quick relief of asthma symptoms. It is the drug of choice for relieving bronchospasm caused by beta-blocker medications.

Long-Term Control Medications

Corticosteroids
Corticosteroid medications for long-term control can be taken orally or inhaled. The oral form typically is used only when long-term control cannot be obtained with inhaled corticosteroids.

Inhaled corticosteroids are used to treat all categories of asthma except the mild intermittent type. They work primarily by reducing inflammation in the asthmatic airway. They also increase receptors for the beta2 agonists and decrease microvascular leaking, which contributes to increased fluid in the bronchial tubes. These factors are felt to be of minor importance compared to the anti-inflammatory benefit.

Oral corticosteroids usually are used only in patients who have severe persistent asthma. They also can be used to treat acute exacerbations, although this use is not common. As with inhaled corticosteroids, their main mechanism of action is the reduction of inflammation.

Cromolyn sodium and nedocromil
These anti-inflammatory agents are delivered by inhalation. They are safe and have minimal side effects, apart from an unpleasant taste. They may be used as long-term anti-inflammatory medications and work best in children. They are not as predictably effective as corticosteroids, however, and should be discontinued if found to be ineffective. They can be used prior to exercise to prevent exercise-induced asthma.

Leukotriene modifiers
Leukotriene modifiers (leukotriene receptor antagonists; e.g., Singulair®, Accolate®) are a class of drugs that block part of the inflammatory cascade that typically occurs in asthma. These drugs, which are taken orally, can be prescribed for adults and children 2 years of age and older.

They often are used with inhaled corticosteroids and should not be used to treat an acute asthma attack. Singulair also is approved to prevent exercise-induced asthma in patients over the age of 15. Side effects include the following:

• Dizziness
• Fatigue
• Fever
• Headache
• Stomach upset

Rare side effects include Churg Strauss syndrome, kidney problems, and elevated liver enzymes.

Long-acting beta2 agonists
Long-acting beta2 agonists relax bronchial smooth muscle, similar to the short-acting beta2 agonists. They work more slowly, however, and for this reason they aren't considered good rescue medications. The body can develop a slight tolerance to these drugs over time, which may render them slightly less effective. They usually are used with inhaled corticosteroids to control symptoms and are particularly useful for treating nocturnal symptoms and exercise-induced asthma. The side effects are the same as those of short-acting beta2 agonists: tachycardia (rapid heartbeat), skeletal muscle tremor, hypokalemia, increased lactic acid, headache, and hyperglycemia.

Theophylline
Theophylline acts as both a bronchodilator and an anti-inflammatory. It usually is used in addition to beta2 agonists and other anti-inflammatory drugs.

Delivery Methods

Metered-dose inhalers
Metered-dose inhalers (MDIs) are the most common delivery system used today. While they are relatively easy to use, children under age 5 often have difficulty with the technique required to use them effectively. To use an MDI, the patient first exhales completely, then places the MDI to the lips, forms a seal around the mouthpiece, and presses on the top of the canister to deliver a measured dose of medication while slowly inhaling. After inhaling slowly, the patient holds his or her breath for a full 10 seconds.

An alternative method is to hold the MDI about 2 inches away from the open mouth and perform the same procedure. This technique has two disadvantages, however: it is tricky to execute properly, and it deposits more than 80% of the medication in the mouth. That much medication deposited in the mouth is especially disadvantageous with inhaled corticosteroids: deposition of inhaled corticosteroids in the mouth increases the risk of oral candidiasis (yeast infection in the mouth). The mouth should be rinsed vigorously with water after administering inhaled corticosteroids.

To reduce the amount of medication that gets deposited in the mouth when using an MDI, a spacer device may be used. A spacer device is a chamber that fits on the mouthpiece of the MDI and the patient seals their lips around the opposite end. The patient exhales completely and then "puffs" the MDI, filling the spacer tube or chamber with the medication. The patient slowly inhales, drawing the medication into the lungs. As with the MDI, it is important to hold the breath for 5 to 10 seconds afterward. Two advantages to using the spacer device are (1) more medication gets into the lungs and (2) the technique is often easier to master.

Breath-actuated MDIs
Breath-actuated MDIs are a variation of the standard MDI. Instead of projecting the medication into the mouth by pressing on the canister, the patient forms a good seal around the mouthpiece and inhales slowly. The inhalation and breath-hold are the same as with a standard MDI. The advantage of the breath-actuated MDI system is that it eliminates the need for hand-breath coordination. Getting the right speed of inhalation—some patients find it difficult to inhale slowly—and the fact that breath-actuated MDIs are not available for all medications are disadvantages.

Dry powder inhalers
Dry powder inhalers are used in patients under 5 years of age. A variety of these are available for specific medications, including beta2 agonists and corticosteroids. They work similarly to breath-actuated MDIs. The patient exhales, then forms seal with the lips around the inhalation port. Unlike breath-actuated MDIs, however, the patient must inhale rapidly. After inhaling deeply, the patient holds his or her breath for 10 seconds. Not all medications are available in dry powder inhaler form. Another disadvantage is that medication can be lost if one accidentally exhales into the device.

Nebulizers
Nebulizers can be used with all classes of inhaled medications but are most commonly used with short-acting beta2 agonists and ipratropium bromide. The medication is placed in a chamber that is connected to an air compressor - powered either by standard electric house current (110 volt) or by a battery. The compressor blows air through the chamber, atomizing the medication so the patient can inhale it through a mouthpiece or facemask. The big advantage of this system is that it requires essentially no hand-breath coordination. It is best to take slow breaths at normal depth, with occasional deep breaths; but any manner of inhaling that the patient finds comfortable is acceptable. This method of drug delivery has obvious advantages for young children. Disadvantages include a longer process than MDI and a lack of portability. Also, it is more expensive than MDIs or dry powder inhalers.

Asthma, Quick-relief Medications, Long-term Medications reprinted with permission from pulmonologychannel.com
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