Asthma treatment involves working with your doctor to create an asthma management plan, taking asthma medicines as needed, avoiding asthma triggers where possible and following lifestyle advice.
Asthma action plans
If you have asthma, you should have your own written asthma plan, devised in conjunction with your doctor.
This will help you to manage your asthma and identify when your asthma is getting worse by recognising your symptoms, understanding your peak flow readings and understanding your asthma medicines.
The asthma action plan should also help you to recognise when you need to adjust your asthma medications, when to contact your doctor and when to go directly to hospital. It should be reviewed with your doctor yearly and whenever there is a change in your asthma treatment.
Medicines for asthma
Medicines for asthma are divided primarily into:
- relievers; and
Most asthma medicines are delivered by an inhaler device, although some are available in tablet or liquid form, or for people in hospital, by injection.
Relievers are medicines that are also known as bronchodilators because they help to open up the airways, helping you to breathe more easily when you’re having difficulty. In general, relievers should be used on an ‘as-needed’ basis for the relief of asthma symptoms. However, if you get exercise-induced asthma, your doctor might recommend that you inhale one or 2 measured doses of your reliever before exercise.
If you are using your reliever more frequently than usual, or your usual dose of reliever medicine isn’t helping as much as it used to, your asthma may not be adequately controlled. See your doctor for advice and a review of your treatment.
Short-acting beta2 agonists
Short-acting beta2 agonists can relieve symptoms quickly and include:
Side effects can include:
- shaking, or tremor;
- feeling anxious or nervous; and
- increased heart rate.
Combination medicine: rapid-onset long-acting beta2 agonist plus inhaled corticosteroid
Combination medicine can be used in certain people with asthma and acts as both a reliever and long-term preventer medicine. The combination medicine Symbicort contains:
- eformoterol (a rapid-onset long-acting beta2 agonist, which can open up the airways quickly and help keep them open); plus
- budesonide (an inhaled corticosteroid).
Side effects may include:
- oral thrush;
- mild throat irritation; and
- hoarse voice.
Preventer medicines are medicines that are taken every day to keep your asthma under control.
Inhaled corticosteroids work by reducing the underlying inflammation of the airways, helping to reduce the incidence and severity of episodes of asthma, and include:
- beclomethasone (e.g. Qvar);
- budesonide (e.g. Pulmicort);
- ciclesonide (e.g. Alvesco); and
- fluticasone (e.g. Flixotide).
Most adults with asthma, even those with infrequent symptoms, benefit from treatment with low-dose inhaled corticosteroids. Inhaled corticosteroids are generally recommended if you have asthma and have:
- experienced symptoms twice or more in the past month; or
- been woken up from sleep due to asthma symptoms once or more in the past month.
Side effects include:
- oral thrush (a fungal infection of the lining of the mouth or throat); and
- hoarse voice.
These side effects can be reduced and prevented by using a spacer device to deliver the medication, and by rinsing your mouth with water after using an inhaled corticosteroid.
Long-term use of high doses of inhaled corticosteroids may result in significant doses of the medicine being absorbed into the bloodstream. This can lead to an increased risk of developing:
- osteoporosis (reduced bone density);
- cataracts (clouding of the normally clear lens of the eye, which interferes with vision); and
Some asthma products contain a combination of a corticosteroid (preventer) and a long-acting beta2 agonist (to help keep the airways open for up to 12 hours), to help keep asthma under control.
Combination products include:
- Seretide (fluticasone plus salmeterol);
- Flutiform (fluticasone plus eformoterol);
- Symbicort (budesonide plus eformoterol); and
- Breo Ellipta (fluticasone plus vilanterol).
These combination products are delivered by inhaler.
Side effects may include:
- oral thrush;
- mild throat irritation; and
- hoarse voice.
Leukotriene receptor antagonists
Montelukast sodium is a leukotriene receptor antagonist, and comes as tablets or chewable tablets (e.g. Singulair, Lukair). It works by blocking substances in your lungs called leukotrienes, which cause narrowing and swelling of the airways. Blocking leukotrienes can improve asthma symptoms and can help prevent asthma flare-ups.
Leukotriene receptor antagonists are usually used as add-on therapy in people whose asthma is not controlled with inhaled corticosteroids. However, they have been found to be less effective than add-on treatment with long-acting beta2 agonists in reducing asthma flare-ups in adults. In some children with asthma, leukotriene receptor antagonists may be used as an alternative to inhaled corticosteroids.
Side effects are usually mild, and include fatigue, headache, stomach upset and fever. There may be a slight increase in the risk of behaviour-related side effects in children – you should discuss this with your doctor.
Cromones, such as sodium cromoglycate (e.g. Intal) and nedocromil sodium (e.g. Tilade) are non-steroidal anti-inflammatory asthma medications. In general, they are thought to work by helping to prevent the release of substances (inflammatory mediators) that contribute to the inflammation and narrowing of the airways.
Side effects can include unpleasant taste (Tilade), throat irritation, cough, nausea and headache.
Anti-immunoglobulin E (IgE)
Omalizumab (Xolair) is an injection that works to block a substance called immunoglobulin E (IgE) that is involved in causing asthma symptoms. IgE is produced by the body in response to allergens. Your doctor may need to do a blood test to measure the amount of IgE before starting treatment.
Omalizumab is used in the treatment of adults and adolescents with uncontrolled moderate to severe allergic asthma who are already taking inhaled corticosteroids and who have raised serum levels of IgE.
Side effects include reactions at the injection site and possible severe allergic reactions that require people to carry an adrenaline auto-injector at all times.
Long-acting beta2 agonists
Long-acting beta2 agonists, or LABAs, help open up the airways. They are useful for people with asthma who find that their asthma is still not controlled even though they are taking their preventer medication. LABAs don’t treat the underlying inflammation of the airways so they should be used in addition to preventer medicine: they are not a substitute for corticosteroids.
The advantage of LABAs is that they can keep the airways open for up to 12 hours after you take them. Salmeterol does not open the airways immediately, so when you’re having asthma symptoms you should still use your reliever medication to help relieve your symptoms immediately. However, eformeterol opens the airways more rapidly, so can be used as a reliever medicine in adults.
Side effects include:
- headache; and
Medicines for treating acute asthma
When asthma symptoms flare up, additional medicines may be needed to control symptoms, including the following.
- Oral corticosteroids, such as prednisolone (e.g. Panafcortelone tablets, Redipred oral solution) or prednisone (e.g. Panafcort tablets), may be prescribed if your asthma is severe or you have a flare-up which is not controlled by reliever medications and inhaled steroids. These are usually given as a short course (5-10 days) to help settle your asthma. Side effects can include: headache, nausea, vomiting, diarrhoea or constipation, insomnia, increased blood pressure, mood and behavioural changes and bruising. Long-term use of oral corticosteroids can increase your risk of developing osteoporosis, cataracts and diabetes.
- Anticholinergic bronchodilators, such as ipratropium bromide (e.g. Atrovent), work by blocking the nerve reflexes that cause the airways to constrict, thereby allowing the airways to remain open. Anticholinergic bronchodilators are sometimes used in combination with beta2 agonists to treat acute asthma. Side effects include dry mouth and throat irritation.
- Theophylline (e.g. Nuelin), one of the older asthma medications, can be used to relieve acute asthma symptoms. Side effects include nausea, vomiting and dizziness.
Inhaled medicine must be delivered to the lungs in an adequate dose. To ensure effective delivery a number of devices have been developed.
Metered dose inhalers
One of the standard inhaler devices is the pressurised metered dose inhaler (pMDI), commonly known as a ‘puffer’. Correct use of pMDIs requires co-ordination and good timing between activation (pressing down on the inhaler) and inhalation. There are also breath-activated pMDIs that can help overcome the problems with timing and co-ordination.
Most adults and children older than about 7 years can be taught to use pMDIs correctly but technique can deteriorate over time. You should check your technique with your pharmacist or doctor periodically.
pMDIs should be washed regularly. The metal canister should be removed and the plastic casing washed by rinsing the mouthpiece through the top and the bottom under warm running water for at least 30 seconds. Next, wash the mouthpiece cover. These should be allowed to dry in the air (NOT with a towel or tissue) before being put back together.
Most MDIs should be washed at least weekly; Intal and Tilade inhalers should be washed and air-dried every day to avoid blocking.
Spacers are excellent devices to help improve delivery of inhaled medication to the lungs.
A spacer is a plastic device which acts as a holding chamber for medication for the few seconds that might elapse between activating your pMDI and breathing in the medicine. By putting one end of the spacer in your mouth and attaching your pMDI to the other end of the spacer, you can inhale your medication effectively without having to press the pMDI and breathe at exactly the same time.
Spacers are usually recommended for children of all ages. A spacer may be recommended for adults who:
- have poor co-ordination when using pMDIs;
- are taking inhaled corticosteroids by pMDI, as spacers can help to reduce adverse effects such as oral thrush; or
- need to administer reliever medication for acute asthma.
Because using a spacer improves the effectiveness of the medication, their use has meant very few people now need nebulisers.
Spacers should be washed monthly, otherwise performance can be adversely affected. They should be washed in warm water with kitchen detergent (do not rinse) and left to drain and air dry. Do not dry your spacer with a cloth or tissue as this produces static build-up that makes the medication stick to the sides. If this happens your lungs will not receive the full dose. The mouthpiece should be wiped clean of detergent.
Correct use of a spacer is important so you should check your technique with your doctor or pharmacist regularly.
Breath-activated dry-powder inhalers
These come in a variety of forms (e.g. Turbuhaler, Accuhaler, Aerolizer and Rotahaler) and they work by releasing the medication only when you breathe in.
These devices usually require less co-ordination than pMDIs, but they do require a certain level of inspiratory breath to activate them.
A nebuliser is a machine that bubbles air (or, in an emergency, oxygen) through a solution of a medication (such as a reliever medication) to create a vapour that can be breathed in through a mouthpiece or a face mask. In general, nebulisers are used only for emergencies or for very severe asthma.
Choosing a device
Selection of the type of device is often a personal preference; some people prefer a pressurised MDI to a breath-activated device and vice versa. However, the individual device you use can depend on the medicine you’re taking, as medication manufacturers often present their medicine in their own type of device. For example, if you’re taking Bricanyl, Pulmicort or Oxis, and you prefer a breath-activated device, you will receive a Turbuhaler, but if you prefer a breath-activated device and you’re taking Serevent or Flixotide you will receive an Accuhaler.
Most complementary therapies have not been researched as extensively as conventional medications for asthma. Very few complementary therapies have been found to be effective in the treatment of asthma, and the National Asthma Council recommends that the use of complementary therapies should not take the place of conventional treatments for asthma.
Complementary medicines and supplements can have side effects and may interact with your other medicines, so if you are thinking of adding complementary medicines or therapies to your asthma management programme, you should consult your doctor for advice first.
You can help control your asthma by:
- not smoking;
- eating a healthy diet and maintaining a healthy weight (which may help with lung health and help with asthma control);
- avoiding asthma triggers if possible; and
- keeping up-to-date with your immunisations (including influenza vaccination), as recommended by your doctor.