Treatment of asthma
General health promotion will help asthmatics feel better. Thus healthy diet and avoiding obesity are important. Not smoking is important: smokers with asthma do not respond to treatment as well as non smokers and lung function deteriorates more rapidly over time than for smokers without asthma or asthmatics who do not smoke.
Although allergen avoidance measures such as mattress covers for dust mites seem intuitively likely to help, recent large trials showed no benefit for either treatment or prevention of asthma. Further studies are needed in targeted patient groups. Specific breathing exercises may be helpful but further research is required.
Reliever inhalers relax the airways if they are narrowed and act to give rapid relief of symptoms. These include salbutamol (albuterol in USA). Generally these are blue inhalers and should be used to relieve symptom when they occur or occasionally to avoid symptoms, for example before exercise.
Relievers do not reduce inflammation of the airways so do not reduce the underlying irritability that causes excess narrowing in responses to smoke, cold or allergens (airway hyperresponsiveness). If relievers are required more than twice a week or at night this suggests the need for a controller inhaler.
Controller inhalers act to reduce airway inflammation so lessen the likelihood of symptoms developing. Most effective are inhaled steroids such as beclomethasone, fluticasone, budesonide, mometasone or ciclesonide (and flunisolone and triamcinolone in the USA). These should be taken regularly even in the absence of symptoms as their job is to control the disease. Which drug is used, at what dose, in which device and how often (once or twice a day) will depend on each individual case in accordance with the guidelines. Make sure you are happy with, informed about, and involved in the choice for your asthma.
In addition many asthmatics take long acting bronchodilators such as eformoterol or salmeterol: often in combination with the inhaled steroid as a combination inhaler (such as seretide or symbicort). Trial data suggests this approach my improve control and reduce the dose of inhaled steroid required. A combination inhaler may be appropriate if asthma symptoms continue despite use of an inhaled steroid alone. These drugs are usually used on a regular once or twice a day basis but additional use to reduce symptom may be feasible at least for symbicort.
Types of inhalers
There are several different types of inhaler device available including metered-dose inhalers (MDI) and dry powder inhalers. Generally MDI devices require good co-ordination between pressing and inhalation. You should decide which is best for you together with the asthma nurse or doctor: the choice depends on the medication you will use. It is clearly sensible to use the same inhaler device for each drug if possible. Over time you my notice local side effects such as hoarseness or loss of voice from inhaled steroids: adding a spacer chamber (such as volumatic) to an MDI may help this: this is a plastic bulb that traps large particles from the inhaler before they lodge in your throat.
Are inhaled steroids safe?
Many asthmatics worry about taking steroids because they have heard that they have side effects. Inhaled steroids are generally SAFE. Whilst steroids taken as tablets can have side effects including bone thinning (osteoporosis), diabetes, high blood pressure and cataracts, their use in inhalers and the type of steroid used minimises the amount of drug that affects the body outside the lungs. These drugs have been used for over 30 years. At recommended doses risk of bone changes or other side effects from inhaled steroids are minimal and less than the risk of uncontrolled asthma. Having said that, it is wise to minimise the dose of inhaled steroid to control asthma. Side effects in the throat may occur including hoarseness of the voice. These may be reduced by adding a spacer device.
Tablets for asthma
A variety of other drugs are available in tablet form for asthma treatment: generally these are added if symptoms persist despite inhaled steroids.
These drugs block one of the inflammatory chemicals thought to be involved in airway narrowing and inflammation in asthma. They are taken as tablets once (Montelukast) or twice a day (Zafirlukast). They can be used in mild asthma before inhaled steroids but are generally added to treatment when inhaled steroids do not fully control symptoms. Response seems to vary and like all medication is important to monitor response by symptom and peak flow diary when adding new treatment. Possible side effects include headache, nausea or rash.
These drugs have been used for asthma for many years. Originally used to relax narrowed airways they may also have anti-inflammatory properties and are now added at low dose to inhaled steroids for some asthmatics. Again monitoring response is important. At low doses the need for blood tests to measure drug levels is generally avoided (high doses can be toxic) as is the main side effect of nausea.
Some patients with severe asthma need to take steroid tablets (prednisolone or prednisone) over long periods of time to control disease. This should be monitored by a physician and in conjunction with inhalers and other asthma drugs. There is a trade off between steroid side effects (see above) and risks from severe asthma. The principle side effects are bone thinning (bone density scans are recommended), skin thinning and easy bruising, and cataracts. The dose of oral steroids should always be minimised.
Steroid tablets are also a mainstay of management of asthma attacks given as short bursts (over 5-7 days) they generally restore control. Asthma attacks should be managed in conjunction with your asthma specialist: even if you have a written management plan let your team know if you have an attack.