Asthma

Updated 12 September 2016

How is asthma treated?

Because asthma is two conditions rolled into one, inflammation and bronchoconstriction of the airways, the most effective treatment consists of a two-pronged approach, treating both factors simultaneously.

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While asthma can’t be cured, it can be controlled in the vast majority of cases. It is a chronic disease and may need long-term treatment and even lifelong management. Modern asthma medication is usually extremely effective.

Your asthma medication, complemented by your lifestyle and the accurate early identification of asthma symptoms, will assist in optimising your asthma control. In most cases good control can be achieved and there is little reason why an asthma sufferer cannot lead a perfectly normal life.

The aim of asthma treatment is to help the patient to:

  • Be free of troublesome symptoms.
  • Minimise the need for reliever therapy because symptoms do not worsen. 
  • Avoid any further acute serious asthma attacks, and to prevent the need for hospitalisation.  
  • Sleep restfully. 
  • Improve lung function as much as possible to (near) normal lung function. 
  • Avoid or minimise any adverse medication-related side-effects. 
  • Maintain normal activity levels, including exercise. A child should be able to attend school regularly and participate fully in all school activities, including sport.

When asthma is controlled, patients can prevent most attacks, avoid troublesome symptoms day and night, and keep physically active. If these objectives are not achieved, and you adhere 100% to your therapy, please visit your doctor to discuss more aggressive treatment, because you should be able to live a normal life.

A comprehensive treatment plan should include the following: 

  • Timely and effective treatment of all aggravating factors such as hay fever, sinusitis, bronchitis and gastro-oesophageal reflux. 
  • Reduced exposure to all possible triggers such as viral infections, flu, allergens, active and passive smoking, excluding exercise. 
  • Patient education: The patient should be able to recognise the warning signs of an asthma attack in time, should adhere to the prescribed medication, should know how to use the inhalers correctly and know how to avoid triggers. The asthma patient must have an action plan ready in case of an emergency.

The exact approach to the treatment of asthma in each individual depends on the severity of your asthma (grades 1 – 4) and age (the approach differs between adults/adolescents and children, and even between children older than five and those that are younger), as explained in tables 1 and 2.

Asthma treatment consists mainly of daily, long-term treatment with an inhaled corticosteroid (often at least six months, in many cases for two years, and even lifelong if necessary), or a leukotriene inhibitor (tablets that also suppress the inflammatory reaction), plus the use of a bronchodilator, to be used when necessary (in the case of an acute attack).

The long-term, daily treatment to control the continuous and underlying inflammation in the airways (the ever-smouldering fire in your airways), is referred to as controller treatment, and the use of bronchodilator treatment to relieve the bronchospasm (to unlock the tight grip, squeezing your airways like a boa constrictor) as reliever therapy.

A. Control of inflammation (Controlling the “FIRE”)

In the past, doctors concentrated on the use of bronchodilators to treat only the bronchoconstriction and largely ignored the main role of the inflamed airways. But growing recognition of the inflammatory basis for asthma has shifted the focus to long-term therapy as the first step for all patients. This treatment of inflammation is undertaken to prevent permanent damage to the airways, known as airway remodelling.

Research has shown that in almost all cases of asthma, the sufferer shows signs of chronic inflammation of the airways. In fact, this underlying and ever-present inflammation may in general be so extensive in asthma patients, that their airways may be narrowed all the time without the patient being aware of it.

It is absolutely essential to treat this chronic inflammation with controller treatment on a daily basis.

The most important controllers are:

1. Inhaled corticosteroids
Widely used inhaled corticosteroids are beclomethasone, budesonide, fluticasone and ciclesonide. Beclomethasone (BDP) is available as Beclate Budesonide is available as Pulmicort and Budeflam. Fluticasone is available as Flixotide and Ciclesonide is available as Alvesco.

The first line of treatment, and gold standard of controller therapy for asthma in adults and adolescents, as well as for children older than two years, is the long-term use of inhaled corticosteroids, with or without the additional use of leukotriene inhibitors (tablets or sprinkles) as add-on therapy.

These medicines have strong anti-inflammatory actions, but won’t be effective against bronchospasm and will thus be effective against the “fire”, but not the “boa constrictor”.

Once inflammation is controlled, the risk of an acute attack diminishes and a bronchodilator can then be used only when acute attacks arise. Inhaled corticosteroids inhibit the whole inflammatory process underlying asthma by reducing the chronic swelling and redness (as part of the inflammation) in the airways of the lungs.

By reducing the swelling, the airway passages are kept more "open". When the mucous membranes are not inflamed they are less sensitive to triggers and the frequency and severity of attacks are reduced. Symptoms will decrease within one to two weeks, with maximum improvement after several weeks. However, control deteriorates within a week after stopping this therapy.

Inhaled corticosteroids are safe in daily dosages needed to control asthma in children (usually 100 – 200 microgram budesonide daily, but about 400 microgram may be needed to control exercise-induced asthma). Higher dosages are not advised as this may impair the child’s growth.

2. Leukotriene inhibitors

Leukotriene inhibitors such as Montelukast, the active ingredient in Singulair and Monte-Air. Leukotriene inhibitors are the newest drugs developed to treat asthma. Leukotriene inhibitors work by blocking the action of leukotrienes, one of the many potent chemical classes which promote the damaging airway inflammation characteristic of asthma. They have anti-inflammatory effects, but are not quite as strong as inhaled corticosteroids.

They are mainly used as add-on therapy to inhaled corticosteroids, when single therapy with the inhaled corticosteroids is insufficient to gain symptom control. Leukotriene inhibitors may sometimes be the first choice of treatment for children, with mild persistent asthma, allergic rhinitis, exercise-induced asthma and ASA (aspirin sensitive asthma).  Being a tablet or sprinkles makes it easier to administer to very young and elderly patients. They are safe for children older than 6 months. Leukotriene inhibitors may reduce the need for high doses of inhaled or oral corticosteroids.

These medication (inhaled corticosteroids with or without leukotriene inhibitors as add-ons) will put out the "fire" of inflammation in asthmatic airways. These asthma treatments need to be taken on a daily basis, even if you are feeling well and your asthma is under control. People often stop taking their medication when they're feeling well, but once you start skipping doses, the "fire" recurs and asthma symptoms arise.

3. Oral corticosteroids (prednisone, prednisolone)

When asthma is not well-controlled short-acting cortisone is prescribed as one of the steps, with inhaled corticosteroids and/or leukotriene-inhibitors and long-acting beta-agonists, but should not be prescribed as long-term treatment, due to known and serious side-effects associated with long-term treatment.

It is prescribed to knock out inflammation as quickly as possible during a period of poor control and an acute attack. Long-term use may lead to growth suppression in growing children and many other side effects.  It is usually prescribed for about ten days in adults and 5-7 days in children (at a dose of 1 – 2 mg/kg/day) to bring the inflammation under control. It is very BAD asthma treatment to just employ inhaled reliever therapy and use courses of oral steroids for lots of severe attacks.  If this is the treatment you are receiving, please speak to your asthma doctor or nurse about starting regular inhaled controller therapy.

4. Long-acting beta-agonists [salmeterol (Serevent) and formoterol (Foradil, Foratec and Oxis)]

Salmeterol is available in normal asthma pumps as well as dry powder devices (Accuhaler).  Formoterol is available as Foradil in a pump and as Foratec and Oxis in drypowder devices known as the DP-haler and Turbuhaler respectively. This inhaler provides a sustained relief of bronchospasm, but its anti-inflammatory action is either unproven or weak. It should never, ever be used as the only asthma medication, never in children, four years old or younger and then only in combination with an inhaled corticosteroid. The bronchodilator effect will last about 12 hours.

When these medicines are used they are always used at the same time as an inhaled steroid. To make this easier, they are also available in single pumps where the steroid is already mixed in with the long-acting beta-agonist. Salmeterol is available, combined with the inhaled corticosteroid fluticasone. This combination is available in an Accuhaler (Foxair and Seretide and an MDI (Foxair, Sereflo and Seretide).

Formoterol is available in combination with the inhaled corticosteroid budesonide in the Turbuhaler device (Symbicord). Symbicord is unusual in that the long-acting beta-agonist also works quickly as a reliever, so it can be used not only twice daily as regular maintenance therapy but also, as needed for emergency treatment. When used in this manner, the frequency and severity of breakthrough attacks are reduced.

5. Sustained-release theophylline preparations

These medications have weak anti-inflammatory action, and long-term treatment is generally not recommended, due to unwanted side effects. In fact, theophylline is regarded as an outmoded treatment for asthma and should only be used if no long-acting beta-agonist inhaler or leukotriene inhibitor is available as an add-on to inhaled corticosteroids.

B. Control during an acute asthma attack (“controlling the SNAKE – relaxing the grip of the boa constrictor”)

Rapidly acting bronchodilators contain salbutamol (Ventolin, Asthavent, Venteze) or fenoterol (Berotec) the most widely used asthma drugs. These are first-line relief therapy for most patients and for mild intermittent cases they are the only drug needed.

They have a rapid onset of action, but their effects wear off over 4 to 6 hours, i.e. they are rapid in onset and action but are short-acting bronchodilators.

They are used to provide instantaneous relief when your chest begins to tighten at the onset of an attack. They act by relaxing the constricted smooth muscles surrounding the bronchioles, thus allowing the airways to widen. The airway passage already narrow due to inflamed and swollen mucous membranes, may close almost completely if the airway muscles start constricting.

The bronchodilator will relieve this muscle constriction, and thus open the airway passage again. This reduces the symptoms of breathlessness and enables sufferers to breathe more freely, but will do little to douse the underlying inflammation. They may be taken prior to exercise in patients who experience exercise-induced asthma.

Both controller and reliever medication are usually administered by inhalation, but some can be given orally or intravenously in the case of an emergency.

It is important to note that the use of relievers (bronchodilators) will not reduce inflammation and the use of controllers (anti-inflammatory action) will not alleviate bronchoconstriction during an acute attack.

Notes on other medication and treatment

You should know some things about other kinds of medication if you are an asthmatic.

Immunotherapy

Sublingual immunotherapy

(SLIT) is safe and effective and recommended as additional therapy for patients older than 5 years who have been diagnosed with hay fever (allergic rhinitis) and mild to moderate asthma. It can only be done if allergy tests (skin or blood tests) show that you are sensitive to ONE allergen, rather than many.

Antihistamines

Antihistamines can be used to alleviate allergic reactions such as hay fever, but are not effective in asthma treatment.

Antibiotics

Antibiotics are seldom necessary, as viral infections are by far the most common triggers of asthma. Antibiotics are ineffective against viral infections, but are effective against bacterial infections.

Sedatives

Sedatives (sleeping pills, tranquilisers) should be strictly avoided because they may suppress breathing and aggravate symptoms. This is especially dangerous in patients with severe asthma.

Cough mixtures

Cough mixtures to suppress your cough won’t offer any relief from asthma, as the cough is usually a sign of poor asthma control and a signal that reliever medication is needed. Leave the cough suppressor and use reliever therapy.

Mucolytic drugs

Mucolytic drugs that loosen mucus in the airways of the lungs can worsen the asthma cough.

Physiotherapy

Physiotherapy to loosen the mucus in the airways of the lungs may actually worsen asthma during an acute attack. Physiotherapy is not indicated for an asthma attack.

Breathing exercises

Breathing exercises where the patient learns to exhale properly by using his diaphragm more effectively to empty the lungs, can sometimes help certain individuals, but is not a substitute for regular controller therapy.

Hydration

Hydration with volumes of fluid for adults and older children is recommended. Dehydration may occur because of poor fluid intake, sweating, and hyperventilation. But care should also be taken not to over-hydrate the patient. It is best to provide only the normal fluid requirements for the child if fluid has to be given intravenously.

Ionisers

Ionisers are ineffective.

Homoeopathic, complementary or alternative medicines

Homoeopathic, complementary or alternative medicines should never be used instead of prescribed medical treatment. There is insufficient medical evidence to recommend this treatment as the sole treatment of asthma. If you do want to try homoeopathic medicines, use them in conjunction with those prescribed by your doctor.

Read more: 

What is asthma?  

What are the causes of asthma? 

How is asthma diagnosed 

Reviewed and updated by Prof Eugene Weinberg, Paediatrician Health24, April 2015.

 

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Asthma Expert

Professor Keertan Dheda has received of several prestigious awards including the 2014 Oppenheimer Award, and has published over 160 peer-reviewed papers and holds 3 patents related to new TB diagnostic or infection control technologies. He serves on the editorial board of the journals PLoS One, the International Journal of Tuberculosis and Lung Disease, American Journal of Respiratory and Critical Medicine, Lancet Respiratory Diseases and Nature Scientific Reports, amongst others.Read his full biography at the University of Cape Town Lung Institute

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