• Theydonotbringanyrelieffromsymptoms(SeeRelievers below)• Theytakeabout14daystobuilduptheprotectiveshield. Youwillnotseeanimmediateeffectbutafter1-2weeksthey willmakeabigdifferenceintheamountofasthmasymptoms youhave.

Relievers• Airwaysthatareinflamedandswollenmayalsoget tighteningofthemusclearoundtheairwayscalledairway spasmorbronchospasm(see“WhatisAsthma?”).This causescough,wheezing(whistlinginthechest)oratight chestwithdifficultbreathing.• Relieversaretheemergencytreatmenttoopenupyour airwayswhentheyareeventighter/moreclosedthan usualinordertomakebreathingeasier.• Relieversproducealmostinstantreliefandareusedas emergencytreatmentforasthmasymptomsorattacks.Always carrythemwithyouforfirstaidtreatment!Butrelievershave noeffectontheswellingintheairwaysorthebuildupof mucus.• Relieversareusedonlywhenyouhavesymptoms.Ifyou needtousearelievermorethan3timesaweek,thenyour asthmaisnotwellcontrolledandyoushouldalsobeon acontroller,oryourmedicationandtechniquemayneedto becheckedbyadoctor.

ControllersSteroid controllers• Steroidsarechemicalsmadebythebody.Onegroup ofsteroids,thecorticosteroids,areusedtotreatasthma. Corticosteroidsaredifferentfromtheanabolicsteroidstaken bysomeathletes.Anabolicsteroidsarenotusedtotreat asthma.• Steroidsarethestrongestcontrollertreatmentforasthma.• Yourdoctorshouldadviseyouwhethertodecreaseor increasethedoseyouaretaking,orstopthesemedicines wherepossible.Donotadjustyourdoseswithoutyour doctor’sadvice.• Theyareusuallygivenbybreathingthemintothelungs.

Inhaled (breathed in) steroids: beclomethasone (sold asBeclate®andQvar®),budesonide(soldasBudeflam®,Inflammide®and Pulmicort®), ciclesonide (sold asAlvesco®) and fluticasone(soldasFlixotide®). Thesemayalsobecombinedwithanothermedicine, such as fluticasone plus salmeterol (sold as Foxair®,Sereflo®andSeretide®)andbudesonideplusformoterol(soldasSymbicord®).

Asthma medicines and how they work

Writtenby:ProfRobinGreenandDrMikeLevinRevisedbyDrMikeLevinandProfRobinGreen2012

Basedonapreviousversionby:ProfRobinGreen,DrMikeLevin

andMrAndyGray

Asthma is a chronic lung disease, which means it cannot becured. But with the right treatment asthma can be kept undercontrolsothatthoseaffectedareabletolivecompletelynormallivesenjoyingfullinvolvementinsportandallotheractivities.

Asthma is causedby inflammation,which is thereall the time.Thiscausesswellingandnarrowingoftheairways(See“Whatis asthma”). On top of this inflammation, people with asthmasometimes have spasm of the airways which may lead to anasthmaattack.Tokeepasthmaundercontrolyouneedtoknowwhat your asthmamedicines are, and how theywork. Thereare two types ofmedicines used in the treatment of asthma –controllersandrelievers.

Medicinesthatareusedregularly,whethersymptomsarepresentornotarecalledcontrollers(sometimespreventers).Controllers work by reducing the inflammation that results in swelling, mucus and muscle tightening around the airways. Becausetheinflammationisthereallthetimetheyareusedeveryday,whetheryoufeelsickorwhetheryoufeelwell,just likepeoplewithhighbloodpressure,epilepsyordiabeteshavetotaketheirmedicineeverydaytostaywell.

Inaddition,butnotinplaceofcontrollers,yourdoctorwillgivea reliever treatment to usewhenyouneed to.Relievers are the emergency treatment to open up your airways when they are even tighter / more closed than usual (an asthma attack).Theyhelptomakeyoufeelbetterforashortwhile,buttheydonottreattheunderlyinginflammation,itisimportanttoknowthatrelyingonrelieversonlyisapoorwaytocontrolsymptoms,becausethesymptomswillkeeponcomingbackaftersometemporaryrelief.

Althoughmedicinesareessential,itisimportanttorememberthattheyarenottheonlypartofasthmatreatment.Youalsoneedtoavoid triggersofasthmaattacks. (See “Risk factors forasthmaandtriggersforasthmaattacks”)

Ifyouareoncontrollermedicine,youneedtotakethistreatmentregularly and correctly. Always make sure somebody showsyou how to use an inhaler correctly. Bring all your pumpsandmedicineswith you toevery visit soyourdoctor, nurseorpharmacistcanexplaintoyouwhattypeofmedicineitis,andcheckwhetheryourtechniqueinusingitisgoodenough.(See“Inhalerdevicesinasthma”)

Controllers• Controllersbuildupaprotectiveshieldintheliningsof thebreathingtubes(calledairwaysorbronchi)andstop swelling,mucusbuild-upandmuscletightening.• Theywillnotworkunlessusedregularly,somustbetaken everyday,evenwhenyouarewell.

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• Inhalationisbestbecausethemedicinegoesstraighttothe lungswhereitisneeded.Becausethesmallestdosepossible isused,side-effectsareuncommon.• Themostcommonsideeffectisahoarsevoiceororalthrush, bothofwhichcanbepreventedbyrinsingyoumouthwith waterafterinhalation.• Side-effectsarereducedifaspacerisused,soifyouare usingahighdose,youshoulduseaspacer.• Childrencantakeupto4puffsperdayofmoststeroids withoutfearofsevereside-effects.• Asthmaticsonhigherdosesofinhaledsteroidsshouldhave theirtreatmentreviewedbyanexpert.

Oral steroids: prednisone (sold as Betabs Prednisone®,Meticorten®, Panafcort®andPulmison®)andprednisolone (soldasAspelone®,Capsoid®,Lenisolone®,Preflam®andPrelone®).

• Oralsteroidsareusuallygivenforonlyashorttimeof 7–14daystorelieveanacuteattackofasthma.Oral steroidsforashorttimearesafeandhighlyeffective.• Manypatientswillkeepsomeathomewhichcanbeused whentheirasthmaisnotundercontrol,withthehelpoftheir actionplan.(See“Keepingasthmaundercontrol”)• Asmallgroupofasthmaticsneedtotakelowdoseoral steroidsonalong-termbasisbecausetheirasthmaisnot controlled,despiteothertypesoftherapy.• Longtermsteroidscanhaveserioussideeffects,andthisform oftreatmentisbecominglesscommonwithbettertherapies.If youareonlongtermoralsteroids,youneedtoseeyour doctorfrequently.Ifyouareonoralsteroidsbutarenottaking inhaledsteroids,thenyourtreatmentneedstobechanged.

Non Steroid controllers:Leukotriene receptor blockers: montelukast (sold asSingulair®andTopraz®)andzafirlukast(soldasAccolate®)

• Thesearebothavailableastabletsforadults.Montelukastis availableforchildrenaschewabletabletsandasaformulation thatcanbesprinkledonfood.• Areusefulforyoungchildrenandasadd-ontherapyfor asthmaticchildrenandadultsnotcontrolledoncurrent controllertherapy.• Areusefulinpatientswhoalsohaveallergicrhinitis.• Areusedtoreducethenumberofasthmaepisodesinduced bythecommoncoldinsmallchildren.• Areextremelysafe.

Long acting Beta agonists: formoterol (sold as Foradil®,Foratec®andOxis®)andsalmeterol(soldasSerevent®).Inhaledlong-acting beta-agonists are only given in combination withsteroidcontrollermedicines. This combination therapymaygetbetterasthmacontrolwithouthavingtoincreasethedoseofthe

inhaled steroid. They may be used in single pumps, togetherwith a steroid inhaler, or as combinations in a single pumporasthmadevice.Thecombinationsthatareavailablearesalmeterolplus fluticasone (sold as Foxair®, Sereflo® and Seretide®) andformoterolplusbudesonide(soldasSymbicord®).Formoterolplusbudesonide (Symbicord®) can be used as required for relievertreatment as well as regularly as a controller. All medicationcontaining long acting beta agonists are not recommended forchildrenbelowtheageof5.

RelieversRelievers are sometimes called “bronchodilators” because theyopen(dilate)theairways(bronchi).

Inhaled relievers: fenoterol (sold as Berotec®), ipratropium(sold as Atrovent®, and Ipvent®), salbutamol (sold as Venteze®andVentolin®),terbutaline(soldasBricanyl®)andtiotropium(soldasForvent®andSpiriva®).Combinationsarealsoavailableinasingleinhalerasipratropiumplussalbutamol(soldasCombivent®)andIpratropiumplusfenoterol(soldasDuovent®).Inhaledrelieversmayalsobeavailableasdrypowderinhalerse.g.AsthvaventDPcaps®,Bricanylturbuhalers®orVentolinAccuhaler®.

• Inhaledmedicinesarebetterbecausetheygostraighttothe airwayswheretheyareneeded.Inhalermedicinescanbe givenbypump(withorwithoutaspacer),otherdevicesorby nebuliser.

Oral relievers• Theyareavailableassyrups,tabletsorcapsules.Theytake longerthaninhaledbronchodilatorstoworkastheyhaveto gothelongwayroundbeforetheyactonthelungs.• Therearetwotypesoforalrelievers:beta-agonists,theophyllines

Oral beta-agonists• Becausehigherstrengthshavetobeusedthaninhaledbeta- agonists,sideeffectssuchasshakiness,headache,sleepless- nessandanervousfeelingoftenoccur.

Theophyllines: aminophylline (sold as Phyllocontin SR®),theophylline (sold as Alcophyllin®, Euphyllin Retard®, Nuelin®,Sandoz Theophylline®, Solphyllin®, Theophen®, Theoplus® andUniphyl®).

• Overthelastfewyearsthesemedicineshavebeenprescribed lessfrequently,mainlybecausetheycommonlyproduceside- effects.Rectallyadministeredtheophyllinescanbepotentially dangerousandarenotrecommended.Howeverlongacting theophyllinesarestillsometimesprescribedasacontroller treatment.• Long-actingtheophyllinesarestartedinlowdosesandare usedonceortwiceaday.Ifyoutakelongactingtheophyllines, yourdoctormaysendyouforabloodtesttomeasurethe leveloftheophyllineinthebloodtodeterminethecorrect dosage.

Other medicines• Homeopathicmedicinesarenotcommonlyrecommendedfor asthma.Ifyoudowishtousethesepleasedonotstopyou child’susualasthmamedicinesasprescribedbyyourdoctor.• Antihistaminescanbeusedforotherallergicconditions suchashayfeverbutarenotconsideredtobestandard asthmamedicines.• Antibioticsarerarelynecessaryasviralinfectionsarebyfar themostcommontriggersofasthmaattacks,butyourdoctor mayusethemforabacterialinfection.• Coughmixturesusuallydonothelpthecoughofanasthmatic. Oralrelieversmaybefoundinsmallamountsincombination coughmixtureremedies,buteventhesearenoteffectivein anasthmaattack.Thecoughmaybeasignofpoorasthma controlandneedinhaledrelievermedicines.

Key points to remember

Controllers• Controllersmustbeusedeverydaywhetheryouarefeeling wellorfeelingunwell.• Inhaledsteroidsarethemosteffectivecontrollermedicines.• Inhaledsteroidsaresafeatdosesusedmostcommonly.• Spacersreducetheriskofside-effects.• Steroidtabletsmayneedtobeusedinashortcourseforan asthmaattack.

Relievers• Relieversareusedforemergencyreliefofsymptoms,but donothelpwiththeunderlyinginflammationorswellingof theairways.• Ifyouneedrelieversalot(morethan3timesperweek)it meansyouarenotgettingenoughcontrollermedicine.• Relieversshouldonlybeusedwhenasthmasymptoms appear,noteveryday.• Thetechniqueofusingyourpumpwillaffecthowwellit relievesyoursymptoms.

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