How Best to Manage Your Asthma

While oral and parenteral bronchodilators do afford some flexibility, and are said to insure better compliance, these agents are most commonly administered by aerosol to reduce systemic side-effects. Methylxanthines, however, are not effective when given as an aerosol and are much less popular at this time.

The approach to management is summarized in Table 3 below.

Table 3.

Asthma Treatment Protocols.

	Clinical Status	Treatment
Mild	Symptoms intermittent	Inhaled corticosteroid (low dose) Or cromolyn/nedocromil Beta agonist as needed for symptoms Leukotriene antagonists
Moderate	Symptoms daily	Inhaled steroid (high dose) And/or cromolyn/nedocromil Beta agonist as needed for symptoms* Leukotriene antagonists
Severe	Frequent symptoms	Inhaled steroid (high dose) And/or cromolyn/nedocromil Beta agonist as needed for symptoms*

* With greater variability consider methylxanthines, long acting beta agonist by inhaler (for example, salmeterol [Serevent®]), steroid burst. NOTE: All these regimens call for the regular use of anti-inflammatory agents (primarily steroid inhalers), but recommend bronchodilators only as needed.

If You Are Pregnant

The treatment of asthma in pregnancy follows the same general principles as that of the non-pregnant asthmatic. It is generally desirable for the welfare of both mother and child to keep the patient relatively free from asthma. Inhaled medications are preferred because less of these medicines will reach the fetus but they should be prescribed if the asthma is not controlled by inhaled medication. Table 4 lists the FDA risk factor category of commonly used asthma medications. It needs to be stressed that the greatest risk to the fetus is uncontrolled asthma.

Table 4.

Risk to Fetus of Allergy and Asthma Medications During Pregnancy.

	Agent	Risk Factor Category
Bronchodilators	Albuterol	C
	Metaproterenol	C
	Terbutaline	B
	Theophylline	C
Anti-inflammatory	Cromolyn sodium	B
	Beclomethasone	C
	Prednisone	Not Rated
	Flunisolide	C
	Triamcinolone	D
Antihistamine	Chlorpheniramine	B
	Brompheniramine	C
	Terfenadine	C
	Astemizole	C
	Tripolidine	B

A=Controlled studies no risk
B=No evidence of risk in humans
C=Risk cannot be ruled out
D=Positive evidence of risk
X=Contraindicated in pregnancy

In Development

Many new approaches and agents for the treatment of asthma have recently become available or are being tested:

• Methotrexate: this chemotherapeutic agent has only been tested in small studies. Potential for serious toxicity. Not recommended at this time for routine care.
• Cyclosporin A: Immunosuppressive agent that stops T-lymphocyte production. Role in asthma uncertain. Potential for serious toxicity.
• Gold salts: Many small studies. Efficacy and role still uncertain.
• IV Immunoglobulins: May act as blocking antibody reducing allergy. Role uncertain.
• Ketotifen: Widely used in other countries. Trials in U.S. have not demonstrated efficacy.
• Triacetyl oleandomycin: Related to antibiotics. Presumably works by altering steroid metabolism.
• Xopenex;®(R-albuterol): Recently approved, the "active" form of albuterol has fewer side-effects.

Others:

• Long acting/selective anticholinergics
• Selective phosphodiesterase inhibitors
• Neurokinin-receptor antagonists
• Colchicine
• Lidocaine (aerosol)
• Monoclonal antibodies directed against adhesion molecules (anti-inflammatory)
• Potassium channel activators

Summary

Patient education, in particular, the avoidance and removal of environmental irritants, is the foundation of asthma management. Any program must be tailored to the patient's individual needs. Complementing this approach is an effective array of agents available to manage both the inflammatory component of asthma, as well as its acute flare-ups. All degrees of asthma require anti-inflammatory therapy. The agents of choice in this category are inhaled steroids. Alternatives exist in the form of cromolyn, nedocromil and, most recently, anti-leukotriene agents. Acute flare-ups require bronchodilator agents administered for symptoms.