9. Asthma Medications

Asthma device quick guide - this is a printable guide to different common medication device systems and technique.

Different types of inhaler devices exist including:

Pressurized Metered Dose Inhaler – drug (steroid, bronchodilator) along with propellant (hydrofluoroalkanes (HFA)) and a surfactant
Dry Powder Inhaler – breath actuated devices
- Ellipta Device, Diskus, Flexhaler, Twisthaler, Diskhaler, Digihaler

Cost can be a substantial burden to patients with asthma. Financial resources and coupons are routinely updated and are available here:
- Asthma Education Resources

Utilization of spacer devices

Utilization of spacer devices is crucial with pressurized metered dose inhalers (pMDI) and ensure delivery of medications to lower airways. Patients should be counselled on use with a pMDI device.

There are multiple types of spacer devices available. At Children’s Mercy, we use the brand AeroChamber Plus^® with mouthpiece or mask set up. Other options include: Optichambers^®, Vortex^® brands.
For any spacer device, ideal set up includes a one way valve mechanism that allows for routine cleaning and fits the inhaler. Assess technique and compliance with spacers at every visit.
Most insurance companies will pay for 1 every 6-12 months.
Spacers should not be scrubbed internally but washed in detergent and allowed to air dry.

Asthma pharmacotherapy chart by classes

A high-level overview of asthma pharmacotherapy chart by classes

Short acting beta agonists (SABA)

These are often rescue medications for bronchodilation. Most commonly albuterol and levalbuterol in the USA . Chart reviewing classes and available versions.

Inhaled Corticosteroids (ICS)

Inhaled Corticosteroids (ICS) are the cornerstone of asthma therapy available. There are a variety of brands and inhalant modalities with their own risks and benefits.

Of significance in pediatrics, one must consider low, medium and high dose in comparison to patient’s age. Comparative dosing for under age 5 is limited. A chart comparing the different options of ICS available and low/medium/high dosing for age 5 and above
Ciclesonide (Alvesco^©) is sometimes used for children with concerns for adrenal insufficiency or growth failure in asthma.

Inhaled Corticosteroids and Long-Acting Beta Agonists (ICS/LABA)

Inhaled Corticosteroids and Long-Acting Beta Agonists (ICS/LABA) are combined medication inhalers including a corticosteroid as well as a long-acting beta agonist. LABAs most often combined for use in the USA are salmeterol, formoterol & vilanterol. LABA should not be used alone in asthma management as this increases risk of death. In the step therapies chart, ICS/Formoterol regimens referred to Symbicort or Dulera as data is on ICS/Formoterol as both a daily and rescue medication. A chart reviewing different types of ICS/LABA available.

Anti-Muscarinic/ Anti-Cholinergic Agents for Asthma

The use of anti-muscarinics agents are discussed in the EPR-4. The EPR-4 gives a conditional recommendation for those >12 years of age of adding long-acting muscarinic antagonists (LAMA) to inhaled corticosteroids (ICS). A conditional recommendation was also given for the addition of LAMA to ICS for those who cannot use a Long-acting beta-agonists (LABA). The GINA report recommends the addition of LAMA to those uncontrolled on ICS/LABA, but recommended against adding to ICS alone or to use LAMA without ICS. Specific review of anticholinergics is provided below for in-depth review.

Leukotriene Receptor Antagonists (LTRA)

Montelukast (Singulair^®) and Accolate (Zafirlukast^®) are the two LTRA available in USA. Montelukast is reviewed in depth below as it is used most often. It is important to note that montelukast has a FDA black box warning in March 2020 due to risk of neuropsychiatric events, including behavior changes, mood changes, agitation, nightmares, night terrors, suicidal thoughts and actions. Therefore, the FDA now recommends that montelukast only be used to treat patients with allergic rhinitis that do not respond to alternative medications. A careful assessment regarding risks and benefits of montelukast is recommended for initiation and continuation of montelukast.
Zafirlukast is available for asthma from age 5 years and older, but its potential side effect of liver damage, need to monitor hepatic enzymes, need to administer twice a day and 1 hour before or 2 hours after meals makes it less appealing in pediatrics.
Montelukast
5-Lipoxygenase Inhibitors: Zileuton (Zyflo^®): Used in mild to moderate chronic asthma as maintenance medication for >12 years of age. Zyflo does not work as a rescue medication. It works by inhibiting leukotriene formation. Original formulation dosing is 600 mg tablet 4 times a day limiting its use in pediatrics. Zyflo CR extended-release dosing is 1200 mg twice a day to be taken 1 hour after meals. Its most serious side-effect is elevation of liver enzymes resulting in a need for hepatic function monitoring monthly for the first 3 months, then quarterly for 1 year, and then annually. Side-effects also include sleep and behavior changes. Clinically important drug interactions include increasing theophylline, propranolol, caffeine and possibly warfarin levels.

Macrolide antibiotics: Azithromycin

Macrolide antibiotics are sometimes used for their anti-inflammatory effects in asthma. The use of azithromycin is not discussed in the EPR-3 or EPR-4. In GINA, patients may be prescribed a 6 month trial of azithromycin 3 times a week for prevention or at onset of illness in the yellow zone. Further information and a review of the safety & efficacy data of azithromycin can be found here.

Oral Steroids

Oral steroids are often used for treatment of an acute asthma exacerbation or chronically in severe asthma. Table comparing different forms of Oral steroids is below.

ORAL CORTICOSTEROIDS COMPARISON TABLE

What is a SMART/MART therapy regimen for asthma?

SMART/MART stands for (Single) Maintenance and Reliever Medication Therapy
For patients on budesonide-formoterol as maintenance therapy, the same inhaler can also be used as needed for symptom relief
This means the patient may need multiple ICS-Formoterol inhalers prescribed.
Notably, formoterol has onset of action within 3-5 minutes and lasts up to 12 hours. Maximum recommended daily dose is 72 mcg.
When compared to albuterol only, SMART approach resulted in fewer exacerbations and decrease in severity of reactions.
Consideration should be given to an emergency albuterol inhaler to be kept in home or school if ICS-Formoterol is not available.
Budesonide-formoterol has been formally studied for this approach, however the data on mometasone-formoterol is currently lacking.

Symbicort Monograph

Dulera Monograph