Discover the different types of asthma medicines and treatments. Learn about the delivery devices for asthma medications, including inhalers and nebulizers. Understand the importance of using inhalers correctly and the role of spacers and valved holding chambers.

Understanding the Three Key Changes in Asthma

When you have asthma, there are three key changes that occur in your airways: swelling, excess mucus, and muscle tightening. These changes make your airways smaller and narrower, making it harder for air to flow through and making it more difficult to breathe. Asthma medicines target these three changes, working to open up your airways and make it easier for you to breathe.

Types of Asthma Medicines and Treatments

There are four main types of asthma medicines and treatments:

• Quick-relief medicines: These work quickly to relieve sudden asthma symptoms and are taken as needed.
• Controller medicines: These help control asthma by addressing the underlying changes in the airways, such as swelling and excess mucus.
• Combination of quick-relief and controller medicines: These medicines are used for both short-term relief and long-term control.
• Biologics: This type of treatment targets specific cells or proteins to prevent swelling in the airways and is for people with certain types of persistent asthma.

It’s important to understand the different types of asthma treatments and how they work to help you manage your asthma effectively.

Delivery Devices for Asthma Medicines

Most asthma medicines are taken by breathing them in using an inhaler or nebulizer. These delivery devices allow the medicine to go directly to your lungs. However, some asthma medicines are also available in pill, infusion, or injectable form.

Inhalers

There are four main types of asthma inhalers:

• Metered dose inhalers (MDIs): These use a propellant to spray the medicine out of the inhaler.
• Dry powder inhalers (DPIs): These do not have a propellant and instead release the medicine when you breathe it in.
• Breath actuated inhalers: These have a dry powder or aerosol medicine that is released when you breathe it in.
• Soft mist inhalers: These do not have a propellant but do spray the medicine out of the inhaler in a soft mist.

For inhalers to work effectively, it’s essential to use them correctly. However, many people make mistakes when using their inhalers, which can lead to uncontrolled asthma. Your doctor or nurse can help ensure you are using your inhaler properly.

Spacers and Valved Holding Chambers

If you use an MDI, it’s recommended to use a spacer or holding chamber with it. These devices attach to the inhaler and help turn the medicine into smaller particles that are easier to inhale.

Nebulizers

A nebulizer machine turns liquid asthma medicine into a mist that you can then breathe in through a mask or mouthpiece. Nebulizers may be easier to use than inhalers for some people, and your doctor can prescribe a nebulizer and the liquid medicine that goes with it.

Importance of Proper Inhaler Technique

Proper inhaler technique is crucial for asthma control. Unfortunately, up to 90% of people who use inhalers make at least one mistake when using them. These mistakes can lead to uncontrolled asthma. That’s why it’s important to have your doctor or nurse watch you use your inhaler to ensure you are using it correctly.

Choosing the Right Delivery Device

The type of delivery device you use for your asthma medicines can make a significant difference in their effectiveness. If an MDI is not easy for you to use, you can talk to your doctor about trying a DPI or breath actuated inhaler instead. Nebulizers may also be an option for some people. Work with your healthcare team to determine the best delivery device for your needs.

Staying Informed and Engaged in Your Asthma Care

Managing your asthma effectively requires staying informed about the different types of asthma treatments and delivery devices, as well as being engaged in your care. Work closely with your doctor to create an Asthma Action Plan and follow it closely. This will help you keep your asthma well-controlled and minimize the impact it has on your daily life.

How Is Asthma Treated? | AAFA.org

Asthma Medicines and Treatment 

Although we cannot cure asthma, we can control it. Everyone’s asthma is different, so you and your doctor need to create an asthma treatment plan just for you. This plan will include an Asthma Action Plan that will have information about your asthma triggers and instructions for taking your medicines.

Watch video on YouTube

There are three changes in the airways when you have asthma: 

1. Swelling inside the airways
2. Excess mucus that clogs the airways
3. Muscles tighten and squeeze around the airways
    

This swelling, clogging, and muscle tightening makes your airways smaller or narrower. This makes it harder for air to flow easily through your airways, and it becomes harder to breathe. There are asthma medicines that target these three changes. They open your airways and make it easier to breathe.

What Are the Different Types of Asthma Medicines and Treatments? 

There are four types of asthma medicines and treatments: 

1. Quick-relief medicines – These medicines work quickly to relieve sudden symptoms. You take them as needed and at the first sign of symptoms.
2. Controller medicines – These medicines help control asthma by correcting the underlying changes in the airways, such as swelling and excess mucus. They can be one or a combination of medicines.
3. Combination of quick-relief and controller medicines – These medicines are used for both short-term relief and control. (They are recommended in the current asthma clinical guidelines, but they have not yet been approved to be used in this way by the FDA.)
4. Biologics – This type of treatment targets a cell or protein to prevent swelling inside the airways. They are for people with certain types of persistent asthma and are given by injection or infusion.
    

The difference between these asthma treatments can be confusing. It is important to understand what each treatment does and how they help your asthma. Learning how to use each correctly can you help keep your asthma well-controlled. Always take your medicines as directed by your doctor and follow your Asthma Action Plan.
 

What Are the Different Types of Delivery Devices for Asthma Medicines? 

You take most asthma medicines by breathing them in using an inhaler or nebulizer. An inhaler or nebulizer allows the medicine to go directly to your lungs. But some asthma medicines are in pill form, infusion form, or injectable form. 

Inhalers (also called puffers) 

There are four types of asthma inhaler devices that deliver medicine: metered dose inhalers (MDI), dry powder inhalers (DPI), breath actuated inhalers, and soft mist inhalers.

• Metered dose inhalers have medicine plus a propellant. The propellant sprays the medicine out of the inhaler in a short burst.
• Dry powder inhalers do not have a propellant and do not spray the medicine out of the inhaler. The medicine is released from the inhaler when you breathe it in.
• Breath actuated inhalers have a dry powder or aerosol medicine. The medicine does not spray out of the inhaler. The medicine is released from the inhaler when you breathe it in.
• Soft mist inhalers do not have propellant, but they do spray the medicine out of the inhaler. They create a cloud of medicine that sprays out softly.

Different types of asthma devices

For inhalers to work well, you must use them correctly. But 70 to 90% of people who use inhalers make at least one mistake when using their inhaler.¹ Inhaler mistakes can lead to uncontrolled asthma. Ask your doctor or nurse to watch you use your inhaler to make sure you are using it correctly.  

Spacers and valved holding chambers

If you use an MDI, it is best to use a spacer or holding chamber with it. This device attaches to your MDI. It turns the medicine into smaller particles that are easier to inhale. 

If an MDI is not easy for you to use, you can also talk with your doctor about a DPI or breath actuated inhaler. These inhalers do not spray medicine out. Instead, you put your mouth around the inhaler’s mouthpiece and breathe in. 

Nebulizers 

A nebulizer machine, or “breathing machine,” turns liquid asthma medicine into a mist. You then breathe in the medicine through a mask or mouthpiece. 

Nebulizers may be easier to use than asthma inhalers for some people. Once the nebulizer is set up and ready to use, simply breathe in and out as normal. 

A doctor should prescribe a nebulizer and the liquid medicine that goes into it. If prescribed, your insurance company may cover the cost. You can also buy a nebulizer from a pharmacy or durable medical equipment (DME) company. Nebulizers purchased online without a prescription may not meet the standards required by the Food and Drug Administration (FDA). Talk with your doctor about which nebulizer is best for you or your child.

Injectables (Biologics) 

Injectable asthma treatment (biologics) are shots or infusions given every few weeks. Shots may be given at the doctor’s office or self-administered at home using an auto-injector device, depending on the type of treatment. 

Infusions are given intravenously at the doctor’s office. This is when a needle attached to a tube is injected into a vein in your arm. The medicine then drips from a bag, through the tube, and into your arm so it goes into your bloodstream.
 

How Do Asthma Treatments Work? 

Asthma treatments work in these ways: 

1. They relax the muscles that tighten around the airways. They “relieve the squeeze.” They can be short- or long-acting. By opening the airways, they help remove and reduce mucus. These medicines are bronchodilators [brahn-ko-DIE-ah-lay-tor] or beta agonists. 
2. They reduce the swelling and mucus inside the airways. These medicines are anti-inflammatories (steroidal and non-steroidal). 

Bronchodilators 

Bronchodilators can be short- or long-acting. If you use short-acting bronchodilators (quick-relief medicines) more than two days a week, talk with your doctor about your asthma control. You may need to make changes to your treatment plan to better control your asthma. 

• Short-acting beta agonists (SABA) are quick-relief medicines. They act quickly and should be taken at the first sign of symptoms. They keep the airways open for four to six hours.
• Short-acting muscarinic antagonists (SAMA) are quick-relief medicines that can be taken with a short-acting beta agonist. They act quickly and should be taken at the first sign of symptoms. They keep the airways open for four to six hours.
• Long-acting beta agonists (LABA) are controller medicines. They are not available as a single medicine. They are found in combination medicines that also have an inhaled corticosteroid. They keep the airways open for up to 12 hours. Only one LABA – formoterol – also acts quickly.
• Long-acting muscarinic antagonists (LAMA) are controller medicines. They are also called anticholinergics and can keep the airways open for 12 to 24 hours. They should be taken daily and will not relieve sudden symptoms.
• Theophylline is a controller medicine that comes as a tablet, capsule, solution, and syrup to take by mouth. It should be taken daily and will not relieve sudden symptoms.
   

Anti-Inflammatories (Steroidal) 

Anti-inflammatories (steroidal) come in many different forms. They are also called controllers because they help to control or prevent asthma symptoms. They reduce swelling and extra mucus inside the airways. They will not relieve sudden symptoms. 

• Inhaled corticosteroids (ICS) are corticosteroids that supplement the natural corticosteroids made by your adrenal glands. They are also called controllers because they help to control or prevent asthma symptoms. They target the airways specifically. They can be taken two ways – daily or as needed. If you are taking ICS as needed, take it with your quick-relief medicine – one right after the other. (The FDA has not yet approved these medicines to be used in this way. If you are interested in learning more about this method of treatment, talk with your doctor.) ICS keep working for 12 to 24 hours. Corticosteroids are not the same as anabolic steroids that are taken by some athletes and banned in many athletic events.
• Oral corticosteroids are taken in pill or liquid form. This medicine may be prescribed as “rescue” for the treatment of asthma attacks that don’t respond to other asthma medicines. They also are used as long-term therapy for some people with severe asthma. Oral corticosteroids have serious long-term side effects compared to inhaled corticosteroids. These can include mood swings, weight gain, high blood pressure, cataracts, osteoporosis, and infections.
   

Other Types of Medicines and Treatments 

• Biologics are shots or infusions given every few weeks. They work by targeting a cell or protein in your body to prevent airway swelling. They are for moderate-to-severe asthma that is hard to treat with ICS and/or other medicines, or people with asthma dependent on OCS. They are for specific types of asthma and will not work for everyone.
• Leukotriene modifiers are taken in pill form. They prevent your body from making or activating leukotrienes. The FDA has strengthened existing warnings about serious behavior and mood-related changes with montelukast (Singulair® and generics).
• Cromolyn sodium is nebulized. It is a mast cell stabilizer that prevents the release of certain natural chemicals, such as histamines and leukotrienes into the body.

Single Maintenance and Reliever Therapy (SMART) 

The 2020 Focused Updates to the Asthma Management Guidelines recommends single maintenance and reliever therapy, also known as SMART. SMART uses one inhaler that has two medicines (combination medicine) as a quick-relief and controller medicine. When on SMART, you can either take your medicine only as needed to relieve sudden symptoms, or you can take it daily as a controller and as needed for quick relief. This is based on your age and the severity of your asthma. 

There is only one long-acting beta agonist – formoterol – that also works as a quick-relief medicine. It acts quickly to open the airways and relieve sudden symptoms. It also works as a controller by keeping the airways open for up to 12 hours. The guidelines recommend using the combination of budesonide and formoterol found in SYMBICORT^©. Formoterol is also available with mometasone furoate in Dulera^©. 

The FDA has not yet approved these medicines to be used in this way. If you are interested in SMART, talk with your doctor.
 

Can Medicine

Alone Help My Asthma? 

Not usually. Although medicines help a lot, they may not be able to do the job alone. You have to avoid the things that cause or trigger your asthma symptoms as much as you can. Asthma triggers can be found outside or inside your home, school, or workplace. 

Improving the indoor air quality in your home is an important part of asthma control. Your indoor air can be more polluted than outside air. Our interactive Healthy Home can show you ways to improve the indoor air quality of your home. A healthier home can reduce your exposure to allergens and irritants.
 

Will I Always Have to Take the Same Amount of Medicine? 

Not always. You will probably take more medicine when you begin treatment to get control of your asthma. Work with your doctor to learn which medicine(s) control your asthma best and how much you need. Once your asthma is well-controlled, your doctor may be able to reduce the amount of medicine you take. The goal is to gain control of your asthma as soon as possible and then control it with as little medicine as possible. Once long-term anti-inflammatory therapy begins, your doctor should monitor you every one to six months. This is to see how your asthma medicines are working and if your asthma is well controlled.
 

Will I Have to Take Medicine All the Time? 

Maybe not. Asthma is a chronic condition (which means you will have it all of your life) that is controllable. Unfortunately, there is no cure for asthma. For that reason, you may have asthma symptoms when exposed to triggers. This is the case even if you don’t have symptoms very often. Your triggers can change over time, and your treatment will depend on two things: how severe your asthma is, and how often you have symptoms. If your asthma is controlled, your treatment will focus on managing symptoms and treatment of episodes when they happen. 

If your symptoms happen at certain times and you know what caused them, you and your doctor can use this information to determine the best treatment. If, for example, you have seasonal asthma because of a specific pollen allergy, you may take medicines only when that pollen is in the air. But asthma that specific is not common. Many people with asthma take some form of medicine most or all of the time.
 

Will Medicine Help Me Sleep Better? 

Yes, if you have nighttime asthma symptoms. Many people wake up with asthma symptoms such as coughing or wheezing. You can control nighttime symptoms by taking asthma medicines as directed by your doctor. 

Removing triggers where you sleep may help you sleep better. Many people are allergic to dust mites and mold found in bedding materials. Using mattress or pillow encasements can help contain those allergens. Dehumidifiers can also be helpful to reduce the humidity in your home that dust mites and mold need to exist. Using air cleaners in your bedroom may also help reduce your exposure to allergens and irritants (animal dander, dust mites, air pollution, etc.).
 

Will Medicine Help Me Breathe Better When I Exercise? 

Yes. Exercising, particularly in cold air, may cause airway swelling or exercise-induced bronchoconstriction (EIB). Quick-relief asthma medicines, taken before exercise, usually control this. If you need repeated doses of quick-relief medicine during and after exercise talk with your doctor. Your medicines may need to be adjusted. Thanks to these medicines, many Olympic and professional athletes have successful sports careers even with their asthma. 

It is important for everyone, including people with asthma, to be as active as possible for good health. Talk with your doctor about how you can be physically active while keeping your asthma well-controlled.
 

Do Asthma Medicines Have Side Effects? 

Yes. All medicines have side effects. Tell your doctor how you are responding to the treatment and if you have any side effects. Follow up often with your doctor so you can control your asthma with the least amount of medicines and with the fewest side effects. 

Medical Review: June 2021 by S. Allan Bock, MD; Maureen George, PhD, RN, AEC, FAAN; and Sumita Khatri, MD, MS

References
1. Bonds, R., Asawa, A. and Ghazi, A. (2015). Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease. Annals of Allergy, Asthma & Immunology, 114(1), pp.74-76.e2.

10 Commonly Prescribed Asthma Medications

Asthma is a chronic lung disease that causes inflammation and swelling of the airways of the lungs. People with asthma experience flare-ups, which are sudden attacks of symptoms. These symptoms include shortness of breath, chronic cough, chest tightness, and wheezing. Typically, symptoms occur after exposure to a trigger, such as allergens, cold air, exercise, stress, and tobacco smoke.

If you have asthma, you already know the importance of avoiding your triggers. The second important part of asthma treatment is using medications to manage your disease.

There are two main types of drugs doctors prescribe to control asthma. It’s important to understand when and why to use each type. The first kind of medication is your long-term control medicine. You might call it your “maintenance” asthma medicine. You use these medicines on a regular basis to control asthma and prevent attacks. The other kind of medicine is your quick-relief, or “rescue” medicine. Should an asthma flare-up occur, you use rescue inhalers to relieve symptoms.

Doctors follow expert guidelines when choosing which medicines to use in treating asthma. Classes of asthma drugs include:

• Immunomodulators. These biologic drugs are monoclonal antibodies that regulate the immune system’s response to allergens. They are maintenance medicines. Common side effects include flu-like symptoms and injection site reactions, such as pain, redness and itching.

• Inhaled corticosteroids. Corticosteroids are powerful anti-inflammatory drugs. By delivering medicine directly into the lungs, they are very effective as long-term control medicines. This also decreases the risk of side effects.

• Leukotriene modifiers. These drugs reduce the action of a chemical involved in swelling and inflammation in the lungs. Your doctor might use this class as a second-line or add-on long-term control medicine. Although rare, liver problems can occur.

• Long-acting beta agonists (LABAs). LABAs are bronchodilators—they open the airways to provide long-term control. This class should only be used in combination with inhaled corticosteroids in people with asthma because using them alone increased the risk of life-threatening asthma attacks.

• Short-acting beta agonists (SABAs). SABAs are also bronchodilators. However, they are rescue medicines because they act very quickly to relax the airways. Rescue inhaler side effects include dizziness, nervousness, shakiness and headache.

After starting treatment, your doctor will regularly monitor your asthma control. Your doctor will want to know how often you experience symptoms, if you have symptoms at night, and how often you use your rescue medicine. You will also need to regularly take peak flow measurements and record them. Your doctor will use all this information to decide whether your current treatment is working.

Common Asthma Medications

Your doctor has more choices to make within each class of asthma medicine. Finding the right treatment for you may involve some trial and error. Here are 10 drugs commonly prescribed for asthma:

1. Albuterol (Accuneb, Proair HFA, Proair Respiclick, Proventil HFA, Ventolin HFA) is a SABA. It comes as a nebulizer solution and as inhalers you use for quick relief. It is the most commonly prescribed rescue inhaler for asthma.

2. Beclomethasone (Beclovent, QVAR) is an inhaled corticosteroid. The usual dose is twice daily for long-term control. To decrease side effects, rinse your mouth and spit after using an inhaled corticosteroid.

3. Budesonide (Pulmicort, Pulmicort Flexhaler) is also an inhaled corticosteroid. It comes as both a nebulizer solution and an inhaler. You usually take it twice a day.

4. Budesonide/formoterol (Symbicort) is a combination of an inhaled corticosteroid and a LABA. It comes as an inhaler you use twice daily.

5. Fluticasone (Flovent HFA) is an inhaled corticosteroid you take twice a day.

6. Fluticasone/vilanterol (Breo Ellipta) combines an inhaled corticosteroid and a LABA that you use once a day.

7. Mometasone (Asmanex Twisthaler) is an inhaled corticosteroid. The dosing can be once or twice daily.

8. Mometasone/formoterol (Dulera) is another combination of an inhaled corticosteroid and a LABA. You use this inhaler twice a day.

9. Montelukast (Singulair) is a leukotriene modifier. It comes as a tablet, chewable tablet, and dissolvable granules. You take it once a day in the evening for long-term control.

10. Omalizumab (Xolair) is an immunomodulator. Your doctor injects this medicine subcutaneously—under the skin. Typically, you need an injection every 2 to 4 weeks. It’s important to keep your appointments to maintain long-term control.

There are several other options available for treating asthma. If your current asthma treatment is not controlling your symptoms, talk with your doctor. It may be possible to get better results with a different drug.

Researchers continue to look for new asthma treatments. There are several drugs in clinical trials for treating asthma. Many of them are biologics, similar to Xolair. However, there is also at least one new oral medication that works differently and may compete with biologic drugs. Talk with your doctor to find information about new asthma medications as they come to market.

Long-Term Control Medications Used to Treat Asthma

Long-term control medications are taken daily on a long-term basis to achieve and
maintain control of persistent asthma.

Examples of
long-term controller medications include: Singulair, Flovent, Advair, Pulmicort, Symbicort and QVAR.

Go to a complete listing of asthma medications.

Long-term control medications (listed in alphabetical order) (EPR-3, p. 214):

Corticosteroids

Block late-phase reaction to allergen, reduce airway hyper responsiveness, and inhibit inflammatory cell migration and activation. They are the most potent and effective anti-inflammatory medication currently available. Inhaled corticosteroids (ICSs) are used in the long-term control of asthma. Short courses of oral systemic corticosteroids are often used to gain prompt control of the disease when initiating long-term therapy; long-term oral systemic corticosteroid is used for severe persistent asthma.

Immunomodulators

Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients >12 years of age who have allergies and severe persistent asthma. Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur.

Leukotriene modifiers

Include leukotriene receptor antagonists (LTRAs) and a 5-lipoxygenase inhibitor. Two LTRAs are available—montelukast (for patients >1 year of age) and zafirlukast (for patients >7 years of age). The 5-lipoxygenase pathway inhibitor zileuton is available for patients >12 years of age; liver function monitoring is essential. LTRAs are alternative, but not preferred, therapy for the treatment of mild persistent asthma (Step 2 care). LTRAs can also be used as adjunctive therapy with ICSs, but for youths >12 years of age and adults they are not the preferred adjunctive therapy compared to the addition of long-acting beta-agonists (LABAs). Zileuton can be used as alternative but not preferred adjunctive therapy in adults.

Long-acting beta-agonists (LABAs)

Salmeterol and formoterol are bronchodilators that have a duration of bronchodilation of at least 12 hours after a single dose.

• LABAs are not to be used as monotherapy for long-term control of asthma.
• LABAs are used in combination with ICSs for long-term control and prevention of symptoms in moderate or severe persistent asthma (step 3 care or higher in children >5 years of age and adults) (Evidence A for >12 years of age, Evidence B for 5–11 years of age).
• Of the adjunctive therapies available, LABA is the preferred therapy to combine with ICS in youths >12 years of age and adults.
• In the opinion of the Expert Panel, the beneficial effects of LABAs in combination therapy for the great majority of patients who require more therapy than low-dose ICS alone to control asthma (i.e., require step 3 care or higher), should be weighed against the increased risk of severe exacerbations, although uncommon, associated with the daily use of LABAs. For patients >5 years of age who have moderate persistent asthma or asthma inadequately controlled on low-dose ICS, the option to increase the ICS dose should be given equal weight to the option of adding LABA. For patients >5 years of age who have severe persistent asthma or asthma inadequately controlled on step 3 care, the combination of LABA and ICS is the preferred therapy.
• LABA may be used before exercise to prevent exercise-induced bronchospasm (EIB), but duration of action does not exceed 5 hours with chronic regular use. Frequent and chronic use of LABA for EIB is discouraged, because this use may disguise poorly controlled persistent asthma.
• In the opinion of the Expert Panel, the use of LABA for the treatment of acute symptoms or exacerbations is not currently recommended.

The Expert Panel concludes the following regarding the use of LABAs (EPR-3, p. 230):

• LABAs are used as an adjunct to ICS therapy for providing long-term control of symptoms. Of the adjunctive therapies available, LABA is the preferred treatment to combine with ICS in youths >12 years of age and adults. LABAs are not recommended for use as monotherapy for long-term control of persistent asthma.
• Use of LABA is not currently recommended to treat acute symptoms or exacerbations of asthma. Studies are underway examining the potential use of formoterol in acute exacerbations and in adjustable-dose therapy in combination with ICS.
• LABA may be used before exercise to prevent EIB, but frequent and chronic use of LABA for EIB may indicate poorly controlled asthma which should be managed with daily anti-inflammatory therapy.
• Safety issues have been raised regarding LABAs. The Expert Panel reviewed the safety data provided to the FDA Pulmonary and Allergy Drugs Advisory Committee as well as the extensive accumulation of clinical trials and meta-analyses on the use of LABA, both as monotherapy and in conjunction with ICS. The Expert Panel concluded that LABAs should not be used as monotherapy as long-term control medication in persistent asthma but that LABAs should continue to be considered for adjunctive therapy in patients >5 years of age who have asthma that requires more than low-dose ICS. For patients inadequately controlled on low-dose ICS, the option to increase the ICS dose should be given equal weight to the addition of a LABA. For patients who have more severe persistent asthma (i.e., those who require step 4 care or higher), the Expert Panel continues to endorse the use of a combination of LABA and ICS as the most effective therapy.

Methylxanthines

Sustained-release theophylline is a mild to moderate bronchodilator used as alternative, not preferred, adjunctive therapy with ICS. Theophylline may have mild anti-inflammatory effects. Monitoring of serum theophylline concentration is essential.

Inhaled corticosteroids

The most potent and consistently effective long-term anti-inflammatory
medications for asthma, with fewer side effects than oral
corticosteroids. Used for management of persistent asthma at all
levels of severity to improve symptoms and pulmonary function.

When is it used?

• Long-term prevention of symptoms; controls, reverses and keeps
  inflammation down.
• Reduce the need for quick-relief medications.

How does it work?

• Anti-inflammatory. Blocks late reaction to allergen and reduces airway
  sensitivity. Inhibits cytokine production, adhesion
  protein activation, and inflammatory cell migration and
  activation at the cellular level.
• Reverse beta₂-receptor down-regulation. Inhibits microvascular leakage.

Possible side effects

• Cough, voice changes (hoarseness), oral thrush (candidiasis)
• In high doses systemic effects may occur, although studies
  have not proven this, and clinical significance of these effects has
  not been established (e.g., adrenal suppression, osteoporosis,
  growth suppression, and skin thinning and easy bruising).
• Some studies of inhaled corticosteroids to treat asthma in
  pre-pubertal children have identified growth delay or
  suppression that appears to be dose-dependent; others have
  not. The potential small risk of adverse effects on linear
  growth is well balanced by efficacy. The clinical significance
  of the findings is unclear at this time. Monitoring growth is recommended.

Other information about using this type of medication:

• Available as MDI, dry power inhaler (DPI) and nebulizer solution.
• Spacer/valved-holding chamber devices with MDIs and mouth washing after inhalation
  decreases the risk of oral side effects and systemic absorption.
• Preparations are not absolutely interchangeable on a mcg or per puff basis.
  New delivery devices may provide greater delivery to airways,
  which may affect dose.
• The risks of uncontrolled asthma should be weighed against the
  limited risks of inhaled corticosteroids. The possible but
  small risk of harmful effects is well balanced by their
  value in controlling asthma.

Oral corticosteroids

Often used to gain prompt control of poorly controlled persistent
asthma, or when starting long-term therapy.

When is it used?

• For short-term (3-10 days) “burst”, broad anti-inflammatory effects.
• For long-term prevention of symptoms in severe persistent or very poorly controlled asthma; controls, reverses and keeps inflammation down.

How does it work?

• Anti-inflammatory. Blocks late reaction to allergen and reduce airway
  sensitivity. Inhibits cytokine production, adhesion protein activation, and inflammatory cell migration and activation at the cellular level.
• Reverse beta₂-receptor down-regulation. Inhibits microvascular leakage.

Possible side effects

• Short-term use: reversible, abnormalities in sugar metabolism,
  increased appetite, fluid retention, weight gain, mood
  change, high blood pressure, peptic ulcer, and rarely aseptic
  necrosis of femur.
• Long-term use is associated with systemic effects: adrenal axis
  suppression, growth suppression, dermal thinning,
  hypertension, diabetes, Cushing’s syndrome, cataracts,
  muscle weakness, and – in rare cases – impaired immune
  function.
• Consideration should be given to coexisting conditions that could be
  worsened by systemic corticosteroids, such as herpes virus
  infections, varicella, tuberculosis, hypertension, peptic
  ulcer, and Strongyloides.

Other information about using this type of medication

• Use at lowest effective dose.
• For long-term use in severe persistent or very poorly controlled asthma, fewer harmful
  effects have been seen with every-other-day morning dosing.

Leukotriene modifiers

May be considered an alternative therapy to low doses of inhaled
corticosteroids for patients >12
years of age with mild persistent asthma, although further clinical experience and study are needed to establish their roles in asthma therapy.

When is it used?

• May be considered as alternative therapy to low doses of inhaled corticosteroids for children with mild persistent asthma, but the position of leukotriene modifiers in therapy has not been fully established. Some studies suggest that leukotriene modifiers may be effective when added to inhaled corticosteroids in the management of moderate persistent asthma (step 3) and when given the night before exercise to prevent exercise-induced bronchospasm.
• Improve symptoms and pulmonary function.
• Reduce the need for quick-relief medications.

How does it work?

• Leukotriene receptor antagonists (e.g. montelukast, zafirlukast) block
  LTD4 receptors; 5-lipoxygenase inhibitors (e.g. zileuton)
  block synthesis of all leukotrienes at the cellular level.

Possible side effects

• Elevations of liver enzymes have been reported with zileuton in some
  patients. Monitoring is recommended.
• In rare cases, adult patients have presented with systemic
  eosinophilia and vasculitis with clinical features consistent
  with Churg Strauss syndrome. These events usually have been
  associated with reducing oral corticosteroid therapy while
  initiating a leukotriene modifier therapy. No causal
  relationship has been established.

Other information about using this type of medication

• Available as tablets. Tablets should be taken at least 1 hour before or
  2 hours after meals for optimum effects for zafirlukast and zileuton.
• Zafirlukast inhibits the metabolism of warfarin and increases prothrombin
  time; it is a competitive inhibitor of the CYP2C9 hepatic
  microsomal isozymes. (It has not affected elimination of
  terfenadine, theophylline, or ethinyl estradiol drugs
  metabolized by the CYP3A4 isozymes.)
• Zileuton is microsomal CYP3A4 enzyme inhibitor that can inhibit the
  metabolism of terfenadine, theophylline, and warfarin. Doses
  of these drugs should be monitored accordingly. Hepatic
  enzymes (ALT) should also be monitored.

Long-acting beta

₂-agonists

Used together with anti-inflammatory medications for long-term
control of asthma symptoms. Should not replace anti-inflammatory medications. Should never be used alone, without an inhaled corticosteroid. Not to be used to treat acute symptoms or flare-ups.

When is it used?

• To improve symptoms and reduce need for quick-relief medication.
• For long-term control of symptoms, especially nighttime symptoms.
• To prevent exercise-induced bronchospasm. However, in some patients this effect may be reduced when used daily as continuous therapy. The clinical significance of this
  finding is unclear.

How does it work?

• Starts working slower but lasts longer than short-acting beta₂-agonists.
• May get better symptom control when added to standard
  doses of inhaled corticosteroids instead of just increasing the corticosteroid dose.
• Bronchodilation: relaxes bronchial smooth muscle following adenylate cyclase
  activation and increases in cyclic AMP producing functional
  antagonism of bronchoconstriction at the cellular level.
• In vitro, inhibits mast cell mediator release, decreases vascular
  permeability, and increases mucociliary clearance.

Possible side effects

• Increased heart rate, shakiness, hypokalemia, prolongation of QTc interval in overdose.
• A diminished bronchoprotective effect may occur within 1 week of
  
  chronic therapy. Clinical significance has not been established.

Other information about using this type of medication:

• Available as MDI, DPI, and tablets. Inhaled long-acting beta₂-agonists
  are preferred because they are longer acting and have fewer
  side effects than time-release pills.
• Should not replace anti-inflammatory medications.
• Not to be used to treat acute symptoms or flare-ups.
• Clinical significance of potentially developing tolerance is not clear because studies
  show symptom control and bronchodilation are maintained.
• May provide better symptom control when added to standard doses of inhaled
  corticosteroid instead of increasing the corticosteroid dosage.

Long-acting Muscarinic Antagonists

Similar to LABAs, long-acting muscarinic antagonist inhalers, or LAMAs, relax the muscles of the airways to help control the symptoms of asthma.

Methylxanthines (theophylline)

Used as add-on therapy to anti-inflammatory medications for long-term
control of asthma symptoms, especially nighttime symptoms.

When is it used?

• Long-term control and prevention of symptoms, especially nocturnal symptoms.
• Produces mild to moderate bronchodilation.
• Theophylline is an alternative, but not preferred, therapy for persistent asthma.

How does it work?

• Bronchodilation: Smooth muscle relaxation from phosphodiesterase inhibition and
  possibly adenosine antagonism (to open up the airways).
• May affect eosinophilic infiltration into bronchial mucosa as well
  as decrease T-lymphocyte numbers in epithelium (to slow mucus production).
• Increases diaphragm contractility and mucociliary clearance (to clear
  mucus from airways).

Possible side effects

• Side effects at usual therapeutic doses include stomach upset, difficulty in
  urination in elderly males with prostate disease, sleeplessness, and
  hyperactivity in some children.
• Dose-related acute toxicities include increased heart rate, nausea and vomiting,
  irregular heart beats (SVT), central nervous system stimulation,
  headache, seizures, vomiting blood, high blood sugar, and hypokalemia.
• Side effects increase with increasing levels of the medication in
  the body. In some children, side effects may occur with lower levels of the
  medication in the body.

Other information about using this type of medication:

• Available as time-release pills and capsules.
• Monitoring is required to maintain serum levels between 5 and 15 mcg/mL.
  Viral illnesses with fever, age, certain medications (e.g.
  erythromycin), and diet can increase absorption and
  bioavailability, which can increase levels of the medication
  in the body.
• Not generally recommended for asthma flare-ups. There is little
  proof of added benefit to optimal doses of inhaled beta₂-agonists.
  Blood concentration of this drug must be monitored closely.

Immunomodulators – Xolair (omalizumab):

Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients ≥ 12 years of age who have allergies, and severe persistent asthma. Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur.

Adding omalizumab to ICS can:

• Reduce exacerbations and subsequent use of systemic steroid bursts
• Reduce daytime allergic asthma symptoms and nighttime awakenings
• Reduce disruptions of daily routine activities

Omalizumab is indicated for patients aged 12 years and older with:

• IgE levels between 30 and 700 IU/mL
• Positive skin test or in vitro reactivity to a perennial aeroallergen
• Allergic asthma symptoms inadequately controlled with ICS

Omalizumab is administered by subcutaneous injection and dosing is based on body weight and baseline serum total IgE concentration. All patients are required to have a baseline IgE between 30 and 700 IU/mL and body weight not more than 150 kg.

Asthma – Treatment – NHS

There’s currently no cure for asthma, but treatment can help control the symptoms so you’re able to live a normal, active life.

Inhalers, which are devices that let you breathe in medicine, are the main treatment. Tablets and other treatments may also be needed if your asthma is severe.

You’ll usually create a personal action plan with a doctor or asthma nurse.

This includes information about your medicines, how to monitor your condition and what to do if you have an asthma attack.

Get an asthma action plan on Asthma UK

Inhalers

Inhalers can help:

• relieve symptoms when they occur (reliever inhalers)
• stop symptoms developing (preventer inhalers)

Some people need an inhaler that does both (combination inhalers).

Watch a short video from Asthma UK to learn how to use your inhaler properly

Read on to learn more about the different types of inhaler.

Reliever inhalers

Most people with asthma will be given a reliever inhaler. These are usually blue.

You use a reliever inhaler to treat your symptoms when they occur. They should relieve your symptoms within a few minutes.

Tell a GP or asthma nurse if you have to use your reliever inhaler 3 or more times a week. They may suggest additional treatment, such as a preventer inhaler.

Reliever inhalers have few side effects, but they can sometimes cause shaking or a fast heartbeat for a few minutes after they’re used.

Asthma UK: reliever inhalers

Preventer inhalers

If you need to use a reliever inhaler often, you may also need a preventer inhaler.

You use a preventer inhaler every day to reduce the inflammation and sensitivity of your airways, which stops your symptoms occurring. It’s important to use it even when you do not have symptoms.

Speak to a GP or asthma nurse if you continue to have symptoms while using a preventer inhaler.

Preventer inhalers contain steroid medicine.

They do not usually have side effects, but can sometimes cause:

• a fungal infection of the mouth or throat (oral thrush)
• a hoarse voice
• a sore throat

You can help prevent these side effects by using a spacer, which is a hollow plastic tube you attach to your inhaler, as well as by rinsing your mouth after using your inhaler.

Asthma UK: preventer inhalers

Combination inhalers

If using reliever and preventer inhalers does not control your asthma, you may need an inhaler that combines both.

Combination inhalers are used every day to help stop symptoms occurring and provide long-lasting relief if they do occur.

It’s important to use it regularly, even if you do not have symptoms.

Side effects of combination inhalers are similar to those of reliever and preventer inhalers.

Asthma UK: combination inhalers

Tablets

You may also need to take tablets if using an inhaler alone is not helping control your symptoms.

Leukotriene receptor antagonists (LTRAs)

LTRAs are the main tablets used for asthma. They also come in syrup and powder form.

You take them every day to help stop your symptoms occurring.

Possible side effects include tummy aches and headaches.

Asthma UK: LTRAs

Theophylline

Theophylline may also be recommended if other treatments are not helping to control your symptoms.

It’s taken every day to stop your symptoms occurring.

Possible side effects include headaches and feeling sick.

Asthma UK: theophylline

Steroid tablets

Steroid tablets may be recommended if other treatments are not helping to control your symptoms.

They can be taken either:

• as an immediate treatment when you have an asthma attack
• every day as a long-term treatment to prevent symptoms – this is usually only necessary if you have very severe asthma and inhalers do not control your symptoms

Long-term or frequent use of steroid tablets can occasionally cause side effects such as:

You’ll be monitored regularly while taking steroid tablets to check for signs of any problems.

Asthma UK: steroid tablets

Other treatments

Other treatments, such as injections or surgery, are rarely needed, but may be recommended if all other treatments are not helping.

Injections

For some people with severe asthma, injections given every few weeks can help control the symptoms.

The main injections for asthma are:

• benralizumab (Fasenra)
• omalizumab (Xolair)
• mepolizumab (Nucala)
• reslizumab (Cinqaero)

These medicines are known as biologic therapies. They are not suitable for everyone with asthma and can only be prescribed by an asthma specialist.

The main side effect is discomfort where the injection is given.

Asthma UK: biologic therapies for severe asthma

Surgery

A procedure called bronchial thermoplasty may be offered as a treatment for severe asthma. It works well and there are no serious concerns about its safety.

You will be sedated or put to sleep using a general anaesthetic during a bronchial thermoplasty.

It involves passing a thin, flexible tube down your throat and into your lungs. Heat is then used on the muscles around the airways to help stop them narrowing and causing asthma symptoms.

Asthma UK: bronchial thermoplasty

Complementary therapies

Several complementary therapies have been suggested as possible treatments for asthma, including:

• breathing exercises – such as techniques called the Papworth method and the Buteyko method
• traditional Chinese herbal medicine
• acupuncture
• ionisers – devices that use an electric current to charge molecules of air
• manual therapies – such as chiropractic
• homeopathy
• dietary supplements

There’s little evidence to suggest many of these treatments help.

There’s some evidence that breathing exercises can improve symptoms and reduce the need for reliever medicines in some people, but they should not be used instead of your medicine.

Asthma UK: complementary therapies for asthma

Work-related asthma

If you seem to have occupational asthma, where your asthma is linked to your job, you’ll be referred to a specialist to confirm the diagnosis.

If your employer has an occupational health service, they should also be informed, along with your health and safety officer.

Your employer has a responsibility to protect you from the causes of occupational asthma.

It may sometimes be possible to:

• substitute or remove the substance that’s triggering your asthma from your workplace
• redeploy you to another role within the company
• provide you with protective breathing equipment#

Find out more:

Page last reviewed: 19 April 2021
Next review due: 19 April 2024

Oral vs inhaled asthma therapy. Pros, cons and combinations

A number of oral and inhaled drugs are available for the long term management of patients with persistent asthma, yet the disease continues to be associated with significant morbidity and mortality. Over the past years, inhaled glucocorticoids have become established as a cornerstone of maintenance therapy because of their demonstrated clinical efficacy, ability to reduce bronchial inflammation and good tolerability. Other inhaled drugs (e.g. sodium cromoglycate, nedocromil, long-acting beta 2 agonists) also play a role in the long term treatment of patients with asthma. However, many patients (especially children and the elderly) find inhalers difficult to use, and poor inhalation technique can affect the amount of drug reaching the lungs and response to therapy. Oral drug administration is simple, but, until recently, oral asthma therapy has primarily consisted of sustained-release theophylline and glucocorticoids. Theophylline has a narrow therapeutic index, necessitating regular monitoring of serum drug concentrations, and long term oral glucocorticoid therapy is associated with potentially serious adverse events including osteoporosis with bone fracture. The recent development of orally administered leukotriene receptor antagonists (e.g. zafirlukast) and 5-lipoxygenase inhibitors (e.g. zileuton) offers novel mechanisms of action and potential solutions to compliance issues associated with regular administration of inhaled asthma therapy. These drugs have demonstrated efficacy as maintenance therapy in patients with asthma and, importantly, lack the adverse effects associated with long term systemic glucocorticoid therapy. Further clinical trials and the increasing use of these new therapies will help to establish the precise role of orally administered leukotriene receptor antagonists and 5-lipoxygenase inhibitors in the long term management of patients with asthma.

Medications for Chronic Asthma – American Family Physician

1. Centers for Disease Control and Prevention. National Center for Health Statistics. National surveillance of asthma: United States, 2001–2010. http://www.cdc.gov/nchs/data/series/sr_03/sr03_035.pdf. Accessed March 15, 2015….

2. Centers for Disease Control and Prevention. National Center for Health Statistics, National Health Interview Survey raw data, 2011. Analysis by the American Lung Association Research and Health Education Division using SPSS and SUDAAN software.

3. Centers for Disease Control and Prevention. National Center for Health Statistics, National Hospital Discharge Survey, 1995–2010. Analysis by the American Lung Association Research and Health Education Division using SPSS software.

4. Centers for Disease Control and Prevention. National Center for Health Statistics. CDC Wonder On-line Database, compiled from Compressed Mortality File 1999–2011 Series 20 No. 2Q, 2014.

5. Barnett SB,
Nurmagambetov TA.
Costs of asthma in the United States: 2002–2007. J Allergy Clin Immunol.
2011;127(1):145–152.

6. Pollart SM,
Compton RM,
Elward KS.
Management of acute asthma exacerbations. Am Fam Physician.
2011;84(1):40–47.

7. Halbert RJ,
Tinkelman DG,
Globe DR,
Lin SL.
Measuring asthma control is the first step to patient management: a literature review. J Asthma.
2009;46(7):659–664.

8. Schatz M,
Sorkness CA,
Li JT,

et al.
Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol.
2006;117(3):549–556.

9. Wood PR,
Smith B,
O’Donnell L,

et al.
Quantifying asthma symptoms in adults: the Lara Asthma Symptom Scale. J Allergy Clin Immunol.
2007;120(6):1368–1372.

10. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda, Md.: National Heart, Lung, and Blood Institute; Revised August 2007. NIH publication no. 07-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed March 11, 2016.

11. Adachi M,
Kohno Y,
Minoguchi K.
Step-down and step-up therapy in moderate persistent asthma. Int Arch Allergy Immunol.
2001;124(1–3):414–416.

12. Koenig SM,
Ostrom N,
Pearlman D,

et al.
Deterioration in asthma control when subjects receiving fluticasone propionate/salmeterol 100/50 mcg Diskus are “stepped-down”. J Asthma.
2008;45(8):681–687.

13. Godard P,
Greillier P,
Pigearias B,
Nachbaur G,
Desfougeres JL,
Attali V.
Maintaining asthma control in persistent asthma: comparison of three strategies in a 6-month double-blind randomised study. Respir Med.
2008;102(8):1124–1131.

14. Bateman ED,
Jacques L,
Goldfrad C,
Atienza T,
Mihaescu T,
Duggan M.
Asthma control can be maintained when fluticasone propionate/salme-terol in a single inhaler is stepped down. J Allergy Clin Immunol.
2006;117(3):563–570.

15. Chauhan BF,
Ducharme FM.
Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children. Cochrane Database Syst Rev.
2012;(5):CD002314.

16. Guevara JP,
Ducharme FM,
Keren R,
Nihtianova S,
Zorc J.
Inhaled corticosteroids versus sodium cromoglycate in children and adults with asthma. Cochrane Database Syst Rev.
2006;(2):CD003558.

17. Adams NP,
Bestall JB,
Malouf R,
Lasserson TJ,
Jones PW.
Inhaled beclomethasone versus placebo for chronic asthma. Cochrane Database Syst Rev.
2005;(1):CD002738.

18. Adams NP,
Bestall JC,
Lasserson TJ,
Jones P,
Cates CJ.
Fluticasone versus placebo for chronic asthma in adults and children. Cochrane Database Syst Rev.
2008;(4):CD003135.

19. Zhang L,
Prietsch SO,
Ducharme FM.
Inhaled corticosteroids in children with persistent asthma: effects on growth. Cochrane Database Syst Rev.
2014;(7):CD009471.

20. DelGaudio JM.
Steroid inhaler laryngitis: dysphonia caused by inhaled fluticasone therapy. Arch Otolaryngol Head Neck Surg.
2002;128(6):677–681.

21. Chan MT,
Leung DY,
Szefler SJ,
Spahn JD.
Difficult-to-control asthma: clinical characteristics of steroid-insensitive asthma. J Allergy Clin Immunol.
1998;101(5):594–601.

22. Federico MJ,
Covar RA,
Brown EE,
Leung DY,
Spahn JD.
Racial differences in T-lymphocyte response to glucocorticoids. Chest.
2005;127(2):571–578.

23. Dolovich MB,
Ahrens RC,
Hess DR,

et al.;
American College of Chest Physicians; American College of Asthma, Allergy, and Immunology.
Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest.
2005;127(1):335–371.

24. Hagan JB,
Samant SA,
Volcheck GW,

et al.
The risk of asthma exacerbation after reducing inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. Allergy.
2014;69(4):510–516.

25. Rank MA,
Hagan JB,
Park MA,

et al.
The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. J Allergy Clin Immunol.
2013;131(3):724–729.

26. Chauhan BF,
Ducharme FM.
Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev.
2014;(1):CD003137.

27. Cates CJ,
Wieland LS,
Oleszczuk M,
Kew KM.
Safety of regular formoterol or salmeterol in adults with asthma: an overview of Cochrane reviews. Cochrane Database Syst Rev.
2014;(2):CD010314.

28. Loymans RJ,
Gemperli A,
Cohen J,

et al.
Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis. BMJ.
2014;348:g3009.

29. Mansur AH,
Kaiser K.
Long-term safety and efficacy of fluticasone/formoterol combination therapy in asthma. J Aerosol Med Pulm Drug Deliv.
2013;26(4):190–199.

30. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Revised 2016. http://ginasthma.org/2016-gina-report-global-strategy-for-asthma-management-and-prevention/. Accessed June 9, 2016.

31. Dahlén SE,
Malmström K,
Nizankowska E,

et al.
Improvement of aspirin-intolerant asthma by montelukast, a leukotriene antagonist: a randomized, double-blind, placebo-controlled trial. Am J Respir Crit Care Med.
2002;165(1):9–14.

32. Leff JA,
Busse WW,
Pearlman D,

et al.
Montelukast, a leukotriene-receptor antagonist, for the treatment of mild asthma and exercise-induced bronchoconstriction. N Engl J Med.
1998;339(3):147–152.

33. Duong M,
Amin R,
Baatjes AJ,

et al.
The effect of montelukast, budesonide alone, and in combination on exercise-induced bronchoconstriction. J Allergy Clin Immunol.
2012;130(2):535–539.e3.

34. Calapai G,
Casciaro M,
Miroddi M,
Calapai F,
Navarra M,
Gangemi S.
Montelukast-induced adverse drug reactions: a review of case reports in the literature. Pharmacology.
2014;94(1–2):60–70.

35. Kubavat AH,
Khippal N,
Tak S,

et al.
A randomized, comparative, multi-centric clinical trial to assess the efficacy and safety of zileuton extended-release tablets with montelukast sodium tablets in patients suffering from chronic persistent asthma. Am J Ther.
2013;20(2):154–162.

36. Sullivan P,
Bekir S,
Jaffar Z,
Page C,
Jeffery P,
Costello J.
Anti-inflammatory effects of low-dose oral theophylline in atopic asthma [published correction appears in Lancet. 1994;343(8904):1006–1008]. Lancet.
1994;343(8904):1006–1008.

37. Markham A,
Faulds D.
Theophylline. A review of its potential steroid sparing effects in asthma. Drugs.
1998;56(6):1081–1091.

38. Nie H,
Zhang G,
Liu M,
Ding X,
Huang Y,
Hu S.
Efficacy of theophylline plus salmeterol/fluticasone propionate combination therapy in patients with asthma. Respir Med.
2013;107(3):347–354.

39. Wang Y,
Lin K,
Wang C,
Liao X.
Addition of theophylline or increasing the dose of inhaled corticosteroid in symptomatic asthma: a meta-analysis of randomized controlled trials. Yonsei Med J.
2011;52(2):268–275.

40. Evans DJ,
Taylor DA,
Zetterstrom O,
Chung KF,
O’Connor BJ,
Barnes PJ.
A comparison of low-dose inhaled budesonide plus theophylline and high-dose inhaled budesonide for moderate asthma. N Engl J Med.
1997;337(20):1412–1418.

41. Theophylline: package insert and label information. http://druginserts.com/lib/rx/meds/theophylline-8/. Accessed August 20, 2015.

42. Hoshino M,
Nakamura Y.
The effect of inhaled sodium cromoglycate on cellular infiltration into the bronchial mucosa and the expression of adhesion molecules in asthmatics. Eur Respir J.
1997;10(4):858–865.

43. van der Wouden JC,
Uijen JH,
Bernsen RM,
Tasche MJ,
de Jongste JC,
Ducharme F.
Inhaled sodium cromoglycate for asthma in children. Cochrane Database Syst Rev.
2008;(4):CD002173.

44. Andersson F,
Kjellman M,
Forsberg G,
Möller C,
Arheden L.
Comparison of the cost-effectiveness of budesonide and sodium cromoglycate in the management of childhood asthma in everyday clinical practice. Ann Allergy Asthma Immunol.
2001;86(5):537–544.

45. Kelly K,
Spooner CH,
Rowe BH.
Nedocromil sodium vs. sodium cromoglycate for preventing exercise induced bronchoconstriction in asthmatics. Cochrane Database Syst Rev.
2000;(4):CD002731.

46. Bonini M,
Di Maria G,
Paggiaro P,

et al.
Potential benefit of omalizumab in respiratory diseases. Ann Allergy Asthma Immunol.
2014;113(5):513–519.

47. Busse WW,
Morgan WJ,
Gergen PJ,

et al.
Randomized trial of omalizumab (anti-IgE) for asthma in inner-city children. N Engl J Med.
2011;364(11):1005–1015.

48. Normansell R,
Walker S,
Milan SJ,
Walters EH,
Nair P.
Omalizumab for asthma in adults and children. Cochrane Database Syst Rev.
2014;(1):CD003559.

49. Oba Y,
Salzman GA.
Cost-effectiveness analysis of omalizumab in adults and adolescents with moderate-to-severe allergic asthma. J Allergy Clin Immunol.
2004;114(2):265–269.

50. Wu AC,
Paltiel AD,
Kuntz KM,
Weiss ST,
Fuhlbrigge AL.
Cost-effectiveness of omalizumab in adults with severe asthma: results from the Asthma Policy Model. J Allergy Clin Immunol.
2007;120(5):1146–1152.

51. Ariano R,
Berto P,
Incorvaia C,

et al.
Economic evaluation of sublingual immunotherapy vs. symptomatic treatment in allergic asthma. Ann Allergy Asthma Immunol.
2009;103(3):254–259.

52. Reinhold T,
Ostermann J,
Thum-Oltmer S,
Brüggenjürgen B.
Influence of subcutaneous specific immunotherapy on drug costs in children suffering from allergic asthma. Clin Transl Allergy.
2013;3(1):30.

53. Penagos M,
Passalacqua G,
Compalati E,

et al.
Metaanalysis of the efficacy of sublingual immunotherapy in the treatment of allergic asthma in pediatric patients, 3 to 18 years of age. Chest.
2008;133(3):599–609.

54. Abramson MJ,
Puy RM,
Weiner JM.
Injection allergen immunotherapy for asthma. Cochrane Database Syst Rev.
2010;(8):CD001186.

55. Reznik M,
Ozuah PO,
Franco K,
Cohen R,
Motlow F.
Use of complementary therapy by adolescents with asthma. Arch Pediatr Adolesc Med.
2002;156(10):1042–1044.

56. Sidora-Arcoleo K,
Yoos HL,
Kitzman H,
McMullen A,
Anson E.
Don’t ask, don’t tell: parental nondisclosure of complementary and alternative medicine and over-the-counter medication use in children’s asthma management. J Pediatr Health Care.
2008;22(4):221–229.

57. McQuaid EL,
Fedele DA,
Adams SK,

et al.
Complementary and alternative medicine use and adherence to asthma medications among Latino and non-Latino white families. Acad Pediatr.
2014;14(2):192–199.

58. Shen J,
Oraka E.
Complementary and alternative medicine (CAM) use among children with current asthma. Prev Med.
2012;54(1):27–31.

59. Boskabady MH,
Javan H,
Sajady M,
Rakhshandeh H.
The possible prophylactic effect of Nigella sativa seed extract in asthmatic patients [published correction appears in Fundam Clin Pharmacol. 2008;22(1):105]. Fundam Clin Pharmacol.
2007;21(5):559–566.

60. Boskabady MH,
Mohsenpoor N,
Takaloo L.
Antiasthmatic effect of Nigella sativa in airways of asthmatic patients. Phytomedicine.
2010;17(10):707–713.

61. Shih CH,
Huang TJ,
Chen CM,
Lin YL,
Ko WC.
S-Petasin, the main sesquiterpene of petasites formosanus, inhibits phosphodiesterase activity and suppresses ovalbumin-induced airway hyperresponsiveness. Evid Based Complement Alternat Med.
2011;2011:132374.

62. Danesch UC.
Petasites hybridus (butterbur root) extract in the treatment of asthma—an open trial. Altern Med Rev.
2004;9(1):54–62.

63. Welsh EJ,
Bara A,
Barley E,
Cates CJ.
Caffeine for asthma. Cochrane Database Syst Rev.
2010;(1):CD001112.

64. Reisman J,
Schachter HM,
Dales RE,

et al.
Treating asthma with omega-3 fatty acids: where is the evidence? A systematic review. BMC Complement Altern Med.
2006;6:26.

65. Chu X,
Ci X,
He J,

et al.
A novel anti-inflammatory role for ginkgolide B in asthma via inhibition of the ERK/MAPK signaling pathway. Molecules.
2011;16(9):7634–7648.

66. Tang J,
Sun J,
Zhang Y,
Li L,
Cui F,
He Z.
Herb-drug interactions: effect of ginkgo biloba extract on the pharmacokinetics of theophylline in rats. Food Chem Toxicol.
2007;45(12):2441–2445.

67. McCarney RW,
Linde K,
Lasserson TJ.
Homeopathy for chronic asthma. Cochrane Database Syst Rev.
2004;(1):CD000353.

68. Kazaks AG,
Uriu-Adams JY,
Albertson TE,
Shenoy SF,
Stern JS.
Effect of oral magnesium supplementation on measures of airway resistance and subjective assessment of asthma control and quality of life in men and women with mild to moderate asthma: a randomized placebo controlled trial. J Asthma.
2010;47(1):83–92.

69. Lau BH,
Riesen SK,
Truong KP,
Lau EW,
Rohdewald P,
Barreta RA.
Pycnogenol as an adjunct in the management of childhood asthma. J Asthma.
2004;41(8):825–832.

70. Schoonees A,
Visser J,
Musekiwa A,
Volmink J.
Pycnogenol® (extract of French maritime pine bark) for the treatment of chronic disorders. Cochrane Database Syst Rev.
2012;(4):CD008294.

71. Smith LJ,
Kalhan R,
Wise RA,

et al.
Effect of a soy isoflavone supplement on lung function and clinical outcomes in patients with poorly controlled asthma: a randomized clinical trial. JAMA.
2015;313(20):2033–2043.

72. Wilkinson M,
Hart A,
Milan SJ,
Sugumar K.
Vitamins C and E for asthma and exercise-induced bronchoconstriction. Cochrane Database Syst Rev.
2014;(6):CD010749.

73. Somashekar AR,
Prithvi AB,
Gowda MN.
Vitamin D levels in children with bronchial asthma. J Clin Diagn Res.
2014;8(10):PC04–PC07.

74. Castro M,
King TS,
Kunselman SJ,

et al.;
National Heart, Lung, and Blood Institute’s AsthmaNet.
Effect of vitamin D3 on asthma treatment failures in adults with symptomatic asthma and lower vitamin D levels: the VIDA randomized clinical trial. JAMA.
2014;311(20):2083–2091.

Asthma: Treatments for Inflammation

What does inflammation have to do with asthma?

If you have asthma, you know that inflammation causes the inner lining of your airways to swell and produce mucus. This inflammation makes the airways more sensitive to certain asthma triggers that cause asthma attacks. Because of this, anti-inflammatory medications are one of the most important treatment options for people with asthma – they help to stop the process that leads to asthma attacks.

Direct anti-inflammatory medications include corticosteroids that are inhaled directly into the lungs or that are systemic (given in a way that the medicine affects the whole body, such as tablets/pills). Mast cell stabilizers and leukotriene modifiers are medicines that work differently and help to improve the anti-inflammatory action of corticosteroids. Monoclonal antibodies (biologic therapy) that offer new ways of treatment targeting the eosinophil cells that are responsible for inflammation in the airways that contribute to asthma.

What are some anti-inflammatory medications for asthma?

Inhaled corticosteroids

Inhaled corticosteroids are the most effective medications you can take to reduce airway swelling and mucus production. The benefits of using these medicines include:

• Fewer symptoms and asthma flare-ups.
• Decreased use of short-acting beta agonists (reliever, or rescue) inhaler.
• Improved lung function.
• Fewer emergency room visits and hospitalizations.
• Better asthma control.

It’s important to remember that inhaled steroids prevent symptoms, but they don’t relieve symptoms. They need to be taken every day and shouldn’t be stopped or decreased unless you’ve discussed this with your asthma care provider.

Inhaled corticosteroids include:

• Beclomethasone dipropionate (Qvar RediHaler®).
• Budesonide (Pulmicort®; Symbicort®). Symbicort combines budesonide and formoterol.
• Ciclisonide (Alvesco® HFA).
• Fluticasone (Flovent® HFA; Advair® HFA and diskus, Wixela® Inhub, AirDuo®). These products combine fluticasone and salmeterol.
• Fluticasone furoate (Arnuity® Ellipta; Breo® Ellipta; Trelegy®Ellipta). Breo combines fluticasone furoate with vilanterol, a long-acting beta agonist. Trelegy combines fluticasone, vilanterol and umeclidinium.
• Fluticasone propionate (ArmonAir® RespiClick).
• Mometasone (Asmanex®, Dulera®). Dulera combines mometasone and formoterol.

Inhaled corticosteroids come in three forms: the metered dose inhaler (MDI), the dry powder inhaler (DPI) and nebulizer solutions. The MDI form works best when used with a valved holding chamber or “spacer.” The chamber helps deliver more medication to your airways and leaves less medicine in your mouth and throat.

Inhaled corticosteroids are safe to use for both adults and children. They have very few side effects, especially at lower doses.

It’s rare, but if you’re taking higher doses, thrush (yeast infection in the mouth) and hoarseness may occur. You can help prevent this things from happening by rinsing your mouth, gargling and spitting after each use, and by using a spacer device with MDIs. If you get thrush, you can treat it easily with an anti-fungal mouthwash that is prescribed by your doctor.

Your doctor will prescribe the lowest dose possible to control your asthma. Many people are concerned about taking “steroids.” These steroids are NOT the same as anabolic steroids that some athletes take to build muscle. The steroids in asthma medications are anti-inflammatory medications, and daily use will lead to asthma control.

Systemic corticosteroids (oral or intravenous)

Systemic corticosteroids are used to treat severe asthma episodes. They are medicines in pill or liquid form that are swallowed (oral), or liquids that are given through a vein (intravenous). These medications are used with other medications to either control sudden and severe asthma attacks, or to treat long-term, hard-to-control asthma.

Systemic steroids take can take up to three hours to begin working and work best after six to 12 hours. Sometimes corticosteroids are taken in high doses for a few days (a steroid burst) or in decreasing doses over time (a steroid taper). They may also be given in a low dose daily, or every other day, for long-term control.

Systemic steroids, available also as generic products, include:

• Cortisone acetate.
• Dexamethasone.
• Hydrocortisone (Cortef®).
• Methylprednisolone (Medrol®, Solu-Medrol®, Depo-medrol®).
• Prednisone (Deltasone®).
• Prednisolone (Prelone®, Pediapred®, Orapred®).

Side effects of systemic steroids tend to occur after long-time use and include a range of issues:

• Acne.
• Weight gain.
• Mood or behavior changes.
• Upset stomach.
• Bone loss.
• Eye changes like glaucoma or cataracts.
• Growth slowdown.

These side effects rarely occur with short-term use. You would only use them on a short-term basis for an acute asthma episode. If you are using steroids over a longer term for hard-to-control asthma, you should be under the care of a pulmonologist or allergist. These providers will consider more advanced treatment and possible referral to other specialties.

Leukotriene modifiers

Leukotrienes are chemicals that occur naturally in our bodies. They cause airway muscles to tighten and mucus production. Leukotriene modifier drugs work by blocking the actions of leukotrienes in the body. Studies show that these drugs improve airflow and reduce asthma symptoms. They come in pill form, taken once or twice per day, and may reduce the need for other asthma medications.

Leukotriene modifiers include:

• Montelukast (Singulair®).
• Zafirlukast (Accolate®).
• Zileuton (Zyflo®).

The most common side effects of leukotriene modifiers are headache and nausea. Leukotriene modifiers may interfere with the proper action of some other medications (for example, theophylline and the blood thinner warfarin). Make sure you inform your doctor of all the medications you are taking.

Monoclonal antibodies

Monoclonal antibodies (biologic therapy) for severe asthma help block the response to airway triggers that cause inflammation. They target the cells that are part of the body’s immune system. These products include a wide range of medicines that are administered either by an injection in your doctor’s office, IV infusion in a clinic or hospital or self-injection at home. People taking biologics receive treatment every 2 to 8 weeks depending on the particular biologic. You should be under the care of a pulmonologist or allergist.

Mast cell stabilizers

Mast cell stabilizers are medications that prevent the release of histamine and other inflammatory substances from cells called mast cells. They are rarely used.

A note from Cleveland Clinic

It’s important to remember that asthma is a chronic (meaning present all the time) inflammation of the airways in the lungs. Daily treatment with the medication your doctor has prescribed for you will lead to better asthma control and, in the long term, healthier lungs.

90,000 Oral corticosteroid treatment started by patients or parents during a severe asthma attack

Relevance

Asthma (bronchial asthma) is a long-term inflammatory disease of the airways that affects about 334 million people worldwide. During severe asthma attacks, people have to visit a medical center or emergency room in a hospital for treatment with corticosteroids, which can be injected directly into a vein or by mouth.Some people with asthma are given oral steroids, which they can take on their own (at the initiative of the patient) or give to their child (at the initiative of a parent) in the event of a severe asthma attack. This approach to treatment is becoming more and more common.

Review question

We searched for studies that compared a) patient-initiated or parent-initiated oral steroids with b) no patient or parent-initiated oral steroid use (for example, a patient visits a medical center or emergency room for further treatment by a doctor or nurse) …The studies were to include either adults aged 18 and over, or school-aged children aged 5 and over. The two reviewers screened search results independently. The initial search was conducted in May 2016.

Results

We reviewed a total of 61 studies, but we did not find any studies that met the above criteria. Five studies were excluded because the study design did not follow our review protocol.Two of these studies posed the correct clinical question, but these studies were excluded because they used a type of study design that did not fit our review protocol.

Conclusions

There is currently no evidence of the safety and efficacy of patient- or parent-initiated oral steroid use in patients with bronchial asthma. This is a concern as this approach to treatment is becoming more common.

News

Recently, considerable attention has been paid to the use of substances and methods prohibited in sports by athletes for medical reasons. Some sources provide conflicting information, others contain a significant amount of inaccuracies and errors. All this ultimately does not allow making a conclusion about this procedure adequate to the real situation. Let’s figure it out.

Asthma.

In the relatively recent past, there were two procedures for obtaining permits for the therapeutic use of substances and methods (TIs) prohibited in sports – full and reduced.The abbreviated one was used just for substances that are used in medicine, incl. for the treatment of bronchial asthma. However, after some time, the shortened procedure was replaced by a simple declaration, that is, there was no need to obtain permits – it was enough to declare in a notification order that they were used for medical reasons, and that was all. At the moment, the declaration has been canceled and for the use of some substances from the prohibited list for medical indications (subject to the maximum allowed dosage), no action is required at all.We are talking about the inhalation use of salbutamol, salmeterol and formoterol, as well as inhalation of glucocorticosteroids, and, accordingly, about their combinations. For all other substances of class “S3. Beta-2-agonists ”, as well as for other uses of the above substances, it is necessary to obtain a TUE.

An interesting fact: with regard to bronchial asthma, some anti-doping organizations can show some flexibility – to issue the so-called “dormant” TUEs.What does this mean? In the event of an asthma attack, physicians may recommend the use of substances for which a TUE is required. In this case, it is possible to submit a so-called retroactive TUE request, i.e. after the treatment has already been carried out. However, Anti-Doping Organizations may issue a customary authorization, provided that after each asthma attack, the Athlete notifies the Anti-Doping Organization and provides medical documents confirming the attack.What is it for? In order for an athlete to be able to carry medicines with him without fears during his career and use them if necessary, because Possession of a substance prohibited in sport is an anti-doping rule violation.

Attention deficit hyperactivity disorder (ADHD)

Methylphenidate, which is prescribed by doctors in other countries for this disease, is not registered as a drug in our country. However, there are cases when foreign athletes participating in Russian teams received a TUE for a given substance.
Here it is worth paying attention to the following point. TUE requests are screened against certain criteria, such as whether there is a reasonable therapeutic alternative to the use of a prohibited substance.

Glucocorticosteroids (GCS)

These are some of the most common substances used by athletes for medical reasons. And of course this is due to incl. with high injury rate.
For substances of this class, not an absolute prohibition applies – they are prohibited only for oral, rectal, intramuscular and intravenous use.Intra-articular injections, ointments, inhalations and other methods of using GCS are not prohibited.

Meldonium, phenotropil and what else?

In 2016, the Prohibited List entered into force, which included meldonium. For many, to say the least, it came as a surprise. However, at the beginning of 2015, this substance was included in the monitoring program. The Monitoring Program is an open document that is published simultaneously with the Prohibited List and can be viewed by anyone.

In general, the Prohibited List is usually updated once a year. But there were times when the update happened more often. In particular, in 2014 there were 2 updates, and for the second time xenon and argon were banned.

Another domestic drug, bemitil, has been included in the monitoring program for 2018.

If we talk about the Prohibited List, then, of course, one should ask the question: by what criteria does a substance get into this document? There are 3 criteria, and any 2 must be met at the same time:
– increase sports results
– pose a threat to the health of the athlete
– are contrary to the spirit of sport.
Many substances fall under these criteria.

Also, a substance becomes prohibited in sports if it can mask the use of other prohibited substances (for example, diuretics).

In accordance with the World Anti-Doping Code, WADA’s decision to include a substance or method on the Prohibited List is final and not subject to discussion.

Procedure for obtaining a permit for TI

The procedure itself is extremely simple – you must fill out a TUE request form and attach medical documents to it that reflect the athlete’s condition at the time of the request, as well as the need to use a prohibited substance.Because consideration of the request takes place without the participation of the athlete, medical documentation should be as detailed as possible.

Requests are directly handled by the Anti-Doping Organization’s Therapeutic Uses Committee (TUAC), which is composed of physicians with experience in sports. Also, KTI can attract independent experts.

When making decisions, the TEC must assess the request for compliance with the following criteria:
a) the Prohibited Substance or Method is necessary to treat an acute or chronic medical condition and that failure to use it would result in a significant deterioration in the Athlete’s health.
b) The use of a Prohibited Substance or Method is highly unlikely to result in any additional improvement in Athletic Performance beyond the expected health improvement of the Athlete.
c) the absence of a reasonable therapeutic alternative to the use of a prohibited substance or method.

The criteria are rather vague and can cover a wide range of conditions. However, the World Anti-Doping Agency has issued several guidelines that help TUEs as accurately as possible in considering TUE requests.

90,000 Information for patients with COPD and bronchial asthma and doctors providing any type of medical care during the COVID-19 epidemic (data as of April 22, 2020)

COPD

• COPD patients are most affected by COVID-19.
• It is strongly recommended for COPD to follow all recommendations for the prevention of respiratory infections, including COVID-19, to minimize the risk of infection.
• At the first sign of a respiratory infection, you should immediately seek medical help by calling 112 or 103.
• There is no scientific evidence to suggest that inhaled (or oral) glucocorticosteroids (“hormones”) should be avoided in COPD patients during COVID-19 epidemics. .
• Patients with COPD should adhere to the regular therapy prescribed by the doctor for the disease.
• Oxygen therapy is prescribed based on standard guidelines (if indicated).

ASTMA

• Patients with bronchial asthma should continue to take prescribed asthma medications, in particular inhaled glucocorticosteroids (ICS) and oral glucocorticosteroids (pCS), if prescribed:

– Asthma medications should be continued as usual. Discontinuation of corticosteroids often leads to a potentially dangerous worsening of asthma,

– For patients with severe asthma, biological therapy (additional treatment with injectable genetically engineered drugs) should be continued and pCGS should not be suddenly stopped, if prescribed;

• All patients should have a written asthma action plan with instructions:

– on increasing basic therapy and therapy for symptom relief (therapy on demand) when asthma symptoms worsen,

– on the appointment of a short course of pGCS in severe exacerbations of asthma (indicating the dose and duration of admission),

– about when and where to seek medical help ( at the first signs of a respiratory infection, you must immediately seek medical help by phone 112 or 103 ),

– Additional personalized advice on asthma management.

For all

• Avoid the use of nebulizers where possible:

– Nebulizers increase the risk of spreading the virus to other patients and healthcare professionals,

– Use of a metered-dose inhaler through a spacer is the preferred treatment for severe exacerbations, use a mouthpiece or tight-fitting mask if necessary.

• Avoid spirometry in patients with confirmed / suspected COVID-19:

– Spirometry can spread viral particles and put staff and patients at risk of infection,

– As long as the viral infection is spreading in your area, postpone spirometry and measurement of peak expiratory flow rate (peak flowmetry) in medical institutions, if it is not urgently needed,

– Observe precautions for contact with respiratory secretions;

• Follow strict infection control rules if aerosol generating procedures are required:

– For example: inhalation, oxygen therapy (including through the nose), sputum induction, manual ventilation, non-invasive ventilation and intubation

• Stay tuned for updates on various official recommendations for the treatment of COPD and asthma, prevention COVID-19 (for example, on the websites rosminzdrav.ru, spulmo.ru).

The main sources of information are data published on the sites goldcopd. org, ginasthma. org

Denk – instructions for use, dosage, composition, analogs, side effects / Pillintrip

Double blockade of RAAS

Risk of arterial hypotension, hyperkalemia and renal dysfunction (incl.including acute renal failure) is higher in the case of double blockade of the RAAS, i.e. with the simultaneous use of angiotensin II receptor antagonists, ACE inhibitors or aliskiren, in comparison with the use of a drug of one of the listed groups. If necessary, the simultaneous use of drugs is recommended to monitor blood pressure, renal function and water-electrolyte balance.

The simultaneous use of enalapril with aliskiren in patients with diabetes mellitus or impaired renal function (Cl creatinine less than 60 ml / min) is contraindicated.

Potassium-sparing diuretics and potassium preparations

ACE inhibitors reduce potassium loss from diuretics.

The simultaneous use of enalapril and potassium-sparing diuretics (such as spironolactone, eplerenone, triamterene, amiloride), potassium preparations or potassium-containing substitutes, as well as the use of other drugs that increase the level of potassium in the blood plasma (for example, heparin) can lead to hyperkalemia.

If necessary, the simultaneous use should be careful and regularly monitor the serum potassium content.

Diuretics (thiazide or loop)

Previous therapy with high doses of diuretics may lead to a decrease in BCC and an increased risk of arterial hypotension during initiation of enalapril therapy. Excessive antihypertensive effects can be reduced by stopping the diuretic, increasing the intake of water or table salt, and also by starting treatment with enalapril at a low dose.

Other antihypertensive drugs

Simultaneous use of beta-blockers, alpha-blockers, ganglion blockers, methyldopa, CCB, nitroglycerin or other nitrates with enalapril can further reduce blood pressure.

Lithium

With the simultaneous use of ACE inhibitors with lithium preparations, a transient increase in the serum concentration of lithium and the development of lithium intoxication were observed. The use of thiazide diuretics can lead to an additional increase in serum lithium concentration and the risk of lithium intoxication with the simultaneous use of ACE inhibitors. The simultaneous use of enalapril with lithium is not recommended. If it is necessary to use such a combination, serum lithium concentrations should be carefully monitored.

Tricyclic antidepressants / antipsychotics (neuroleptics) / anesthetics / narcotics

The simultaneous use of certain anesthetics, tricyclic antidepressants and antipsychotics (antipsychotics) with ACE inhibitors can lead to an additional decrease in APF.

NSAIDs

The simultaneous use of NSAIDs (including selective COX-2 inhibitors) can weaken the antihypertensive effect of ACE inhibitors or angiotensin II receptor antagonists.

NSAIDs and ACE inhibitors have an additive effect on increasing serum potassium levels, which can lead to impaired renal function, especially in patients with impaired renal function. This effect is reversible.

In rare cases, the development of acute renal failure is possible, especially in patients with impaired renal function (for example, in elderly patients or with severe hypovolemia, including with the use of diuretics).

Before starting therapy, it is necessary to replenish the BCC.It is recommended to monitor kidney function during treatment.

Oral hypoglycemic agents and insulin

Epidemiological studies suggest that the simultaneous use of ACE inhibitors and hypoglycemic agents (insulin and hypoglycemic agents for oral administration) may lead to an increase in the hypoglycemic effect with the risk of hypoglycemia. Most often, hypoglycemia develops in the first weeks of therapy in patients with impaired renal function.

Ethanol

Ethanol enhances the antihypertensive effect of ACE inhibitors.

Sympathomimetics may reduce the antihypertensive effect of ACE inhibitors.

Acetylsalicylic acid, thrombolytics and beta-blockers

Safe simultaneous use of enalapril with acetylsalicylic acid (as an antiplatelet agent), thrombolytics and beta-blockers.

Weakens the effect of drugs containing theophylline.

Allopurinol, cytostatics and immunosuppressants (including methotrexate, cyclophosphamide)

Concomitant use with ACE inhibitors may increase the risk of leukopenia. With simultaneous use with allopurinol, the risk of developing an allergic reaction increases, especially in patients with impaired renal function.

Cyclosporin

Concomitant use with ACE inhibitors may increase the risk of hyperkalemia.

Antacids

Antacids may decrease the bioavailability of ACE inhibitors.

Gold preparations

When using ACE inhibitors, incl. enalapril, patients receiving intravenous gold preparation (sodium aurothiomalate), a symptom complex was described, including hyperemia of the skin of the face, nausea, vomiting, arterial hypotension.

There was no clinically significant pharmacokinetic interaction of enalapril with hydrochlorothiazide, furosemide, digoxin, timolol, methyldopa, warfarin, indomethacin, sulindac and cimetidine. With simultaneous use with propranolol, the concentration of enalaprilat in the blood serum decreases, but this effect is clinically insignificant.

Allopurinol: decrease in the number of leukocytes in the blood, leukopenia.

Analgesics, NSAIDs (eg acetylsalicylic acid, indomethacin): the hypotensive effect of enalapril may be weakened.

Antihypertensive drugs: enhancement of the hypotensive effect of enalapril, especially while taking diuretics.

Anesthesia and narcotic drugs: increase in blood pressure lowering.

Potassium, potassium-sparing diuretics (especially spironolactone, amiloride, triamterene), as well as other agents (eg heparin): increased serum potassium levels.

Cooking salt: weakening of the antihypertensive effect.