Asthma Treatment: Steroids and Other Anti-Inflammatory Drugs

The key treatments for asthma are steroids and other anti-inflammatory drugs. These asthma drugs both help to control asthma and prevent asthma attacks.

Steroids and other anti-inflammatory drugs work by reducing inflammation, swelling, and mucus production in the airways of a person with asthma. As a result, the airways are less inflamed and less likely to react to asthma triggers, allowing people with symptoms of asthma to have better control over their condition.

What Are the Main Types of Steroids and Anti-Inflammatory Drugs for Asthma?

The main types of anti-inflammatory drugs for better asthma control are steroids or corticosteroids. Other anti-inflammatory treatments include leukotriene modifiers, anticholinergics, and immunomodulators.

What Are Inhaled Steroids?

Inhaled steroids are the mainstay treatment for controlling asthma. The use of inhaled steroids leads to:

• Better asthma control
• Fewer symptoms and flare-ups
• Reduced need for hospitalization

Steroids may help asthma symptoms during an attack but are slow acting and can take several hours to take effect. Dosages of inhaled steroids in asthma inhalers vary.

Inhaled steroids need to be taken daily for best results. Some improvement in asthma symptoms can be seen in 1 to 3 weeks after starting inhaled steroids, with the best results seen after 3 months of daily use.

Inhaled steroid medications for better asthma control include:

• Beclomethasone dipropionate (Qvar)
• Budesonide (Pulmicort)
• Budesonide/Formoterol (Symbicort) - a combination drug that includes a steroid and a long-acting bronchodilator drug
• Fluticasone (Flovent)
• Fluticasone inh powder (Arnuity Ellipta)
• Fluticasone/Salmeterol (Advair) - a combination drug that includes a steroid and a long-acting bronchodilator drug
• Mometasone (Asmanex)
• Mometasone/ formoterol (Dulera) - a combination drug that also includes a long-acting bronchodilator drug

Inhaled steroids come in three forms: the hydrofluoroalkane inhaler or HFA (formerly called a metered dose inhaler orMDI), dry powder inhaler (DPI), and nebulizer solutions.

What Are the Side Effects of Inhaled Steroids?

Inhaled steroids have few side effects, especially at lower doses. Thrush (a yeast infection in the mouth) and hoarseness may occur, although this is rare. Rinsing the mouth, gargling after using the asthma inhaler, and using a spacer device with metered dose inhalers can help prevent these side effects. Thrush is easily treated with a prescription antifungal lozenge or rinse.

Inhaled steroids (asthma inhalers) are safe for adults and children. Side effects with these anti-inflammatory asthma inhalers are minimal. Your doctor will prescribe the lowest dose that effectively controls your child's or your asthma.

On a side note, many parents are concerned about giving their children "steroids." Inhaled steroids are not the same as anabolic steroids that some athletes take to build muscle. These steroids are anti-inflammatory drugs, the cornerstone of asthma therapy. There are many benefits of using anti- inflammatory asthma inhalers to manage asthma.

To learn more about using inhaled steroids in children, see ishonest's article on Childhood Asthma.

What Are the Benefits of Using Inhaled Steroids?

The benefits of inhaled steroids for better asthma control far exceed their risks, and include:

• Reduced frequency of asthma attacks
• Decreased use of beta-agonist bronchodilators (quick relief or rescue inhalers)
• Improved lung function
• Reduced emergency room visits and hospitalizations for life-threatening asthma

How Do Prednisone and Systemic Steroids Work to Increase Asthma Control?

Using systemic steroids (steroids taken by mouth or by injection that can affect the entire body) such as methylprednisolone, prednisone, and prednisolone helps to treat severe asthma episodes, allowing people to gain better asthma control. Prednisone and other steroid drugs may be used to help control sudden and severe asthma attacks or in rare cases to treat long-term, hard-to-control asthma.

Most often, prednisone or another steroid is taken in high doses for a few days (called a steroid burst) for more a severe asthma attack.

Side effects of systemic steroids can include weakness, acne, weight gain, mood or behavior changes, upset stomach, bone loss, eye changes, and slowing of growth. These side effects rarely occur with short-term use, such as for an acute asthma attack.

For in-depth information, see ishonest's article on Prednisone and Asthma.

How Do the Leukotriene Modifiers Improve Asthma Control?

Montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo) are called leukotriene modifiers. Leukotrienes are inflammatory chemicals that occur naturally in our bodies and cause tightening of airway muscles and production of mucus. Leukotriene modifier drugs help control asthma by blocking the actions of leukotrienes in the body. Studies show that these medications are helpful in improving airflow and reducing asthma symptoms.

The leukotriene modifiers are taken as pills and have been shown to decrease the need for other asthma medications. These medications have also been shown to be effective in people with allergic rhinitis (nasal allergies) and may be effective in people with both allergic rhinitis and allergic asthma.

What Are the Side Effects of Leukotriene Modifiers?

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

How Do Immunomodulators Work to Improve Asthma Control?

Mepolizumab (Nucala) is a biologic therapy that has been found to control the blood cells that often trigger asthma. Nucala targets Interluken-5 (IL-5) which regulates the levels of blood eosinophils (the type of white blood cells that helps trigger asthma). Genetically engineered, Nucala keeps IL-5 from binding to eosinophils and, thereby, lowers the risk of a severe asthma attack.

Nucala is administered by injection once every 4 weeks and is meant to be used in conjunction with other asthma treatments as a maintenance medication. By using Nucala, patients have been found to not only experience fewer asthma incidents, but they are able to reduce the amount of their other asthma medications. Side effects include headache and a hypersensitivity reaction that can cause swelling of the face and tongue, dizziness, hives, and breathing problems.

Omalizumab(Xolair), an immunomodulator, works differently from other anti- inflammatory medications for asthma . Xolair blocks the activity of IgE (a protein that is overproduced in people with allergies) before it can lead to asthma attacks. Immunomodulator treatment has been shown to help reduce the number of asthma attacks in people with moderate to severe allergic asthma whose symptoms are not controlled with inhaled steroids.

Xolair, a prescription maintenance medication, is given by injection every 2 to 4 weeks. It's recommended for people with moderate to severe allergic asthma. Side effects may include redness, pain, swelling, bruising or itching at the injection site, joint pain, and tiredness. There is a slight increase in risk for problems with the heart and circulation to the brain in people using Xolair. It also carries a boxed warning about a severe, potentially life-threatening allergic reaction (anaphylaxis).

Reslizumab (Cinqair) is also maintenance medication. It is used along with regular asthma medicines when those medicines cannot fully control your asthma. This medicine is given every 4 weeks as an intravenous injection over a period of about an hour. This drug works by reducing the number of a specific type of white blood cells called eosinophils that play a role in causing asthma symptoms. It can reduce severe asthma attacks. Side effects include anaphylaxis (a severe allergic reaction), muscle pain, and cancer.

How Do Anticholinergics Work to Improve Asthma Control?

Tiotropium bromide (Spiriva Respimat) is a long-acting anticholinergic medication. Anticholinergics relax and enlarge (dilate) the airways in the lungs, making breathing easier (bronchodilators). Tiotropium bromide is a maintenance medication used once a day along with other maintenance drugs when tighter control is needed for symptom relief . It is not a rescue inhaler. This drug may be used by individuals age 6 and older who have asthma.

What Are the Side Effects of Anticholingergics?

The most common side effects are pharyngitis, headache, bronchitis, and sinusitis. Other reactions include dizziness, diarrhea, cough, allergic rhinitis, urinary tract infections and urinary retention, yeast infections in the mouth or throat, and high blood pressure (hypertension).

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