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ASTHMA TREATMENT OVERVIEW — Asthma is a common lung disease affecting millions of people worldwide. It is characterized by narrowing of the airways in the lungs (figure 1). Symptoms of asthma include wheezing, coughing, chest tightness, and shortness of breath. These symptoms tend to come and go and are related to the degree of airway narrowing in the lungs. Different things can trigger symptoms in people with asthma, including viral illnesses (eg, the common cold), allergens, exercise, medications, or environmental conditions.
Living with asthma can be challenging, but it is possible to manage it successfully with medications and other measures. The goals of asthma treatment are to control symptoms as well as possible and prevent asthma attacks (also called "exacerbations").
This topic will discuss the treatment of asthma in adolescents (defined as children 12 years and older) and adults. Other topics about asthma are also available. (See "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the Basics)" and "Patient education: Exercise-induced asthma (Beyond the Basics)".)
Topics about asthma in children under 12 are also available. (See "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education: Asthma treatment in children (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)
WHAT CAN I DO ON MY OWN? — There are several things you can do to keep your asthma well controlled. These include learning about your condition, understanding how and when to use all your medications (and when to seek emergency help), avoiding things that make your symptoms worse, keeping track of your symptoms, and seeing your doctor regularly for monitoring.
Education — It's important to make sure that you learn and understand:
●What asthma is – Being familiar with the definition of asthma, how to recognize symptoms, and the role of medication can empower you in taking care of yourself. This can also help family members and friends understand your condition.
●When to use your medications – Asthma medicines work in different ways, so it is important to know which medication will treat asthma symptoms quickly and which ones are used to prevent symptoms from happening. Keeping an asthma "action plan" can help prepare you to treat symptoms when they happen. (See 'Action plan' below.)
●How to use your inhalers – Many people with asthma need to use multiple inhalers, and some require different techniques. It's important to know how to use each so you get the medication you need when you need it.
●What triggers your asthma – This allows you to avoid or limit exposure to things that make your symptoms worse. (See 'Controlling asthma triggers' below.)
It helps to develop a strong relationship with your health care provider so you feel comfortable asking questions and sharing your concerns. Ideally, you and your provider will work together to make decisions about treatment. In addition to seeing your provider for regular visits, there are things you can do to monitor your asthma over time. (See 'Monitoring your asthma over time' below.)
Monitoring your asthma over time — In order to successfully manage your asthma, you will need to monitor your condition over time. This involves being aware of the frequency and severity of your symptoms and measuring your lung function regularly.
Asthma diary — Your health care provider may recommend keeping a daily asthma diary when your symptoms are not well controlled or when starting a new treatment. In the diary, you can keep track of when you have symptoms (such as coughing, wheezing or shortness of breath); which medications you took and when; and your peak expiratory flow (PEF), also called "peak flow" (form 1). (See 'Measurement of lung function' below.)
Your provider may also suggest completing a self-assessment form periodically, such as before a routine visit (form 2). This type of diary can help you and your provider to determine whether your treatment plan needs to be adjusted.
Measurement of lung function — Monitoring your lung function involves measuring your PEF or forced expiratory volume in one second (FEV1), ie, the rate at which you can exhale. When asthma is causing your airways to narrow, air flows more slowly out of your lungs, causing the PEF or FEV1 measurement to be lower.
Your health care provider might suggest that you check your PEF at home periodically by blowing into a device called a peak flow meter. These devices are inexpensive and easy to use. (See "Patient education: How to use a peak flow meter (Beyond the Basics)".)
FEV1 is measured by spirometry. This test is usually done in a doctor’s office or pulmonary function laboratory, about every one to two years, or more often if asthma symptoms are more frequent or severe. However, it can now be done for home monitoring by patients or in conjunction with telehealth visits.
PEF and spirometry are used to monitor your lung function and response to medication, and help guide decisions regarding treatment.
Action plan — An asthma "action plan" is a form or document that your provider can help you put together; it includes instructions about how to monitor your symptoms and what to do when they happen. Different forms are available for this purpose (form 3). An action plan can tell you when to add or increase medications, when to call your provider, and when to get immediate emergency help. This can help you, or your family members, know what to do in the event of an asthma attack. Different people can have different action plans, and your action plan may change over time.
Action plans usually include three categories, based on your symptoms and/or your PEF (see 'Measurement of lung function' above):
●Green – Green means your lungs are functioning well. When symptoms are not present or are well controlled, you can typically continue your regular medicines and activities.
●Yellow – Yellow means your airways are somewhat narrowed, making it difficult to move air in and out; asthma symptoms may be more frequent or more severe. This is usually treated with a short-term change or increase in medication. You should change or increase your medication according to the plan that was discussed with your provider.
●Red – Red means your airways are severely narrowed and symptoms are severe; this requires immediate treatment, often with several medications.
When to call for emergency help — It's important to know when to get emergency help, for example, if your medications do not work quickly to relieve symptoms. Severe asthma attacks can lead to death if not treated promptly.
In most areas of the United States and Canada, you can call 9-1-1 for emergency medical assistance. You should not attempt to drive yourself to the hospital if you are having severe asthma symptoms, and you should not ask someone else to drive. Calling for emergency help is safer than driving for two reasons:
●From the moment emergency personnel arrive, they can begin evaluating and treating your asthma. When driving in a car, treatment is generally delayed until you arrive in the emergency department.
●If a dangerous complication of asthma occurs on the way to the hospital, emergency personnel will able to treat the problem immediately. It is not safe to try to drive a car and treat a severe asthma attack at the same time.
An oral steroid medication (eg, prednisone) is often given for 5 to 10 days to treat an asthma attack and reduce the risk of a second attack.
Controlling asthma triggers — The factors that set off and worsen asthma symptoms are called "triggers." Identifying and avoiding your asthma triggers is essential in keeping symptoms under control. Common asthma triggers generally fall into several categories:
●Allergens, including dust, pollen, mold, cockroaches, mice, cats, and dogs
●Respiratory infections, such as the common cold, the flu, or COVID-19
●Irritants, such as tobacco smoke, chemicals, and strong odors or fumes
●Physical activity, especially if you are breathing cold or dry air while exercising
●Certain medications, including beta blockers (used to treat high blood pressure)
●Hormonal changes related to the menstrual cycle (in some women)
After identifying potential asthma triggers, you and your health care provider should develop a plan to deal with the triggers. This can involve avoiding the trigger, limiting your exposure to the trigger if it's not practical to avoid it entirely, or taking an extra dose of medication in advance (for example, before you exercise).
Trigger avoidance is discussed in more detail separately. (See "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)
Regular medical appointments — People with asthma need to see their health care provider regularly. For adolescents and others whose asthma is well-controlled, this may mean appointments once or twice a year. If your asthma is not well-controlled, you will likely need to go more frequently.
At these visits, your provider will ask about the severity and frequency of your asthma symptoms to assess how well your treatment is working. If your asthma has been well-controlled for at least three to six months, your provider may suggest continuing with your current treatment or possibly decreasing ("stepping down") your medication. If your provider thinks you are a candidate for stepping down, they will work with you to decide which medication(s) to decrease or stop, and monitor you closely to ensure that your symptoms remain under control.
It's important to let your provider know if your asthma symptoms get worse at any point in time. If this happens, they will review your medications, ensure that you are avoiding triggers and using your inhaler(s) properly, and suggest changes in medications or dosing as appropriate.
Sometimes other, related conditions can make asthma symptoms worse; these may need to be addressed in order to achieve good asthma control. Examples include gastroesophageal (acid) reflux (when stomach contents back up into the esophagus, causing symptoms like heartburn and regurgitation); nasal congestion or sinus disease; excess weight; and sleep apnea (a condition that makes you stop breathing for short periods during sleep).
APPROACH TO ASTHMA TREATMENT — The approach to asthma treatment depends on the frequency and severity of your symptoms, including asthma attacks, as well as your personal preferences and risk factors. Asthma is typically categorized as "intermittent" or "persistent." Your health care provider will work with you to review your symptoms and adjust your treatment plan over time.
Intermittent asthma — People with intermittent asthma are defined as those who have the following characteristics:
●Daytime symptoms occur two or fewer days per week
●Nighttime symptoms awaken you two or fewer nights per month
●Asthma does not interfere with daily activities
●A short-acting bronchodilator is needed to relieve asthma symptoms fewer than two days a week (see 'Asthma quick-relief medications' below)
●Oral steroids are needed no more than once per year to treat increased symptoms
If your asthma is triggered only by vigorous exercise (called "exercise-induced asthma" or, more accurately, "exercise-induced bronchoconstriction") and can be prevented by pre-treatment with a short-acting bronchodilator medicine, you will likely be considered to have intermittent asthma. Exercise-induced asthma is discussed in more detail separately. (See "Patient education: Exercise-induced asthma (Beyond the Basics)".)
Persistent asthma — People with persistent asthma have symptoms regularly. If you have persistent asthma, there may be days when your symptoms prevent you from doing your normal activities, and you may often be awakened from sleep.
Based on the frequency of symptoms as well as the measurement of your lung function, your provider will classify your persistent asthma as mild, moderate, or severe. This will help determine the best treatment plan for you.
To determine whether your asthma is mild, moderate, or severe, your provider will consider the frequency of asthma attacks requiring treatment with oral steroids over the past year. They will also consider how many days per week you have one or more of the following:
●Symptoms such as cough, wheeze, and shortness of breath
●Nighttime asthma symptoms that awaken you from sleep
●Symptoms that need treatment with a bronchodilator (reliever medication)
●Symptoms that affect your ability to participate in normal activities
Regardless of the severity of your asthma and the medications you take, it is important that your provider assess how well controlled your asthma is at each visit. Treatment is then adjusted as needed until good asthma control is achieved.
ASTHMA QUICK-RELIEF MEDICATIONS — Quick-relief medications are used to relieve asthma symptoms when they happen.
Short-acting beta-agonists — Short-acting beta-agonists (SABAs) are a type of "bronchodilator" medication. They relieve symptoms rapidly by temporarily relaxing the muscles around narrowed airways, allowing more air to get through. These medications are sometimes referred to as "quick-acting relievers" or "rescue medication"; some people also refer to them as "emergency inhalers." People with intermittent asthma, the mildest form of asthma, will require treatment with SABAs only occasionally.
SABAs include albuterol (called salbutamol in many countries) (brand names: ProAir HFA, Proventil HFA, Ventolin HFA) and levalbuterol (also called levosalbutamol) (brand name: Xopenex HFA). "HFA" means the medicine comes in a metered dose inhaler (MDI) using the propellant hydrofluoroalkane (figure 2 and figure 3). Albuterol is also available in another type of inhaler, called a dry powder inhaler (sample brand name: ProAir RespiClick). Taking your SABA through an inhaler allows the medication to take effect rapidly (within three to five minutes) and minimizes side effects. Your inhaler will come with specific instructions for use; more information about inhaler techniques is also available separately. (See "Patient education: Inhaler techniques in adults (Beyond the Basics)".)
SABAs like albuterol and levalbuterol are meant to be used as needed for relief of asthma symptoms, or preventively prior to an activity that is known to provoke symptoms (for example, 5 to 20 minutes before exercise). There is no benefit to using them on a regular, scheduled basis. If your symptoms are consistently occurring on more than two days per week, you should discuss your treatment plan with your health care provider. Other medications are more effective for controlling persistent symptoms.
Another kind of SABA, epinephrine, is available without a prescription. It comes in an inhaler (brand name: Primatene Mist) or as a liquid that you inhale through a small device (brand name: Asthmanefrin). However, inhaled epinephrine can cause dangerous side effects, especially if you use too much, so health care providers generally do not recommend these non-prescription devices for treating asthma symptoms.
Inhaled steroids with formoterol — Formoterol is a type of medication called a long-acting beta-agonist (LABA). It starts to work quickly, like SABAs, but the effects last longer. It always comes together with an inhaled steroid medication that reduces inflammation in the airways (see 'Inhaled steroids' below). Various inhalers that combine inhaled steroids with formoterol are available (sample brand names: Breyna, Dulera, Symbicort). They are often used as daily controller medicines but can be used for quick relief of asthma symptoms as well. (See 'Inhaled steroids plus a long-acting bronchodilator' below.)
ASTHMA CONTROLLER MEDICATIONS — People with persistent asthma generally need to take medication on a daily basis to keep their asthma under control, even if they do not have symptoms every day. The medications used for this are called "long-term controller" medications.
Some controller medications come in an inhaler, while others are taken as a tablet. If you take a controller medication, the type and dose will depend on how frequently you have symptoms and how severe they are. If you have severe asthma, your doctor may prescribe more than one controller medication.
While controller medications help to reduce the frequency of asthma attacks, you will still need to keep quick-relief medications with you at all times, so you can treat symptoms if they do happen. (See 'Asthma quick-relief medications' above.)
Inhaled steroids — Inhaled steroids (also known as glucocorticoids or corticosteroids) decrease inflammation (swelling) of the airways over time. The steroids used to treat asthma are entirely different from the ones athletes sometimes take to build muscle. Regular treatment with an inhaled steroid reduces the frequency of symptoms (and the need to use short-acting medication for symptom relief), improves quality of life, and decreases the risk of serious attacks.
A number of different inhaled steroid medications are available, all of which are taken once or twice a day. Sometimes, a daily steroid is prescribed along with another medication, called a long-acting bronchodilator. (See 'Inhaled steroids plus a long-acting bronchodilator' below.)
Side effects — Unlike oral steroids (taken as a tablet or liquid by mouth), very little of the inhaled steroid is absorbed into the bloodstream, and there are few side effects. However, as the dose of inhaled steroid is increased, small amounts of the inhaled medication are absorbed into the bloodstream, and the risk of long-term side effects increases.
The most common side effect of low-dose inhaled steroids (as are typically used to control mild to moderate persistent asthma) is a fungal infection in the mouth called “oral candidiasis” (also known as thrush). This can usually be prevented by rinsing your mouth and gargling with water immediately after using your inhaler. If you have a metered dose inhaler, it may also help to use a spacer device; this promotes delivery of medication directly to the lungs, with less deposited in the mouth (figure 3).
A hoarse voice and sore throat are less common side effects of inhaled steroids; these can often be managed by switching to a different medication or type of inhaler.
Higher doses of inhaled steroids are sometimes used to control more severe persistent asthma. Rare but possible side effects of long-term, high-dose inhaled steroid treatments, besides oral candidiasis, include cataracts, increased pressure in the eye (glaucoma), easy bruising of the skin, and increased bone loss (osteoporosis).
The risk of these complications is far less with inhaled steroids compared with oral steroids (eg, prednisone). Nevertheless, to minimize the risk, your health care provider will prescribe the lowest possible dose to control your asthma.
Inhaled steroids plus a long-acting bronchodilator — Many adults and adolescents with persistent asthma take a long-acting beta-agonist (LABA) in combination with an inhaled steroid. LABAs work for 12 or more hours, longer than short-acting beta-agonists (SABAs); they include formoterol, salmeterol, and vilanterol. An inhaler that contains both a steroid and a LABA is usually preferred (sample brand names: Advair, Breo, Dulera, Symbicort). An inhaler containing budesonide and formoterol (brand names: Breyna, Symbicort) can be used as a daily controller medication and is sometimes also used for quick relief of asthma symptoms when they happen; this is because formoterol takes effect as quickly as a SABA such as albuterol. (See 'Inhaled steroids with formoterol' above.)
Tiotropium (brand name: Spiriva) is another type of long-acting bronchodilator, called a long-acting muscarinic antagonist (LAMA). It is used more frequently for treating chronic obstructive pulmonary disease (COPD), but is sometimes used (along with an inhaled steroid) as an asthma controller medication if other treatments have not worked well.
Leukotriene modifiers — Leukotriene modifiers are long-term controller medications that you take as a tablet, rather than through an inhaler. They include montelukast (brand name: Singulair), zafirlukast (brand name: Accolate), and zileuton (brand name: Zyflo). Leukotriene modifiers work by opening narrowed airways, decreasing inflammation, and decreasing mucus production. They may be an alternative to inhaled steroids for mild asthma, and they have few side effects (occasionally, agitation or depression can occur). However, they are less effective in controlling asthma. They are sometimes used in addition to inhaled steroids for more severe asthma.
Leukotriene modifiers can be used to prevent symptoms before exposure to a trigger or before exercising; however, they need to be taken two or more hours in advance. (See "Patient education: Exercise-induced asthma (Beyond the Basics)".)
MEDICATIONS FOR MORE SEVERE ASTHMA — People with more frequent or severe asthma symptoms may need to take other medications in addition to those described above. These medicines are called "biologics" because they contain antibodies that target different components of the hyperactive allergic immune response. They are given by subcutaneous or intravenous injection in intervals from two weeks to two months.
Anti-IgE agent — Omalizumab (brand name: Xolair) is a medication that targets immunoglobulin E (IgE) or allergy antibodies. Omalizumab can help in people whose asthma symptoms are triggered by allergies. It works best in people who are allergic to year-round allergens (such as dust mites, mold, animal dander, or cockroaches) as confirmed by skin or blood tests. Omalizumab is given by injection every two to four weeks. It is given either in the doctor's office or at home after the first several doses are observed in the office, because allergic reactions can occur.
Anti-IL-5 agents — Interleukin 5 (IL-5) is a protein that is associated with a certain type of asthma called "eosinophilic asthma." People with this type of asthma may benefit from medications directed against IL-5, such as benralizumab (brand name: Fasenra), mepolizumab (brand name: Nucala), and reslizumab (brand name: Cinquair).
These medications are only used in people with severe asthma who have increased eosinophils (a type of white blood cell) based on blood test results. They are typically given by injection or intravenously (through an IV) in a doctor's office or clinic, although in some cases a person can be trained to do the injections at home. The schedule varies from every four weeks to every eight weeks, depending on which medication you take. Allergic reactions can sometimes happen with these medications, so you will need to be observed after the first dose.
Anti-IL4/IL-13 agent — IL-4 and IL-13 are also proteins that contribute to eosinophilic asthma. People with severe eosinophilic asthma may benefit from a medication called dupilumab (brand name: Dupixent) that blocks the action of IL-4 and IL-13. Dupilumab is also effective for people who have required daily oral steroids (eg, prednisone) to control their asthma. It is given by injection every two weeks; some people are able to do their own injections at home after receiving training.
Anti-TSLP agent — Thymic stromal lymphopoietin (TSLP) is another protein that can contribute to severe asthma. Patients with both eosinophilic asthma and non-eosinophilic asthma may benefit from the anti-TSLP agent tezepelumab (brand name: Tezspire). It is given by injection in a doctor’s office every four weeks.
MEDICATIONS FOR ASTHMA ATTACKS — In general, an asthma attack or "exacerbation" refers to an increase in symptoms above one's usual level in a way that interferes with normal activities. Asthma attacks can come on over a few days or can happen suddenly. Some people have mild asthma attacks that can be treated at home, while others have severe asthma attacks that require emergency medical services. Review your asthma action plan to make sure you know exactly what medicines to take and what dose, and when your health care provider wants you to call the office or call for emergency help.
Quick relief medicine — For most people, treating an asthma attack involves using a quick-relief medicine (albuterol, levalbuterol, or budesonide-formoterol). The usual dose is 2 inhalations (puffs), or up to 4 inhalations when asthma symptoms are severe (meaning you are short of breath when sitting still). If you still have symptoms after 20 minutes, you can repeat the dose.
Oral steroids — Most providers recommend a 5 to 10 day course of oral steroids (also called glucocorticoids) for asthma attacks. Side effects include insomnia, hunger, agitation, and mood alteration, but they generally can be tolerated for a short period during which restoration of normal breathing is the priority. If you have diabetes, steroids can cause your blood sugar to go up. Check with your provider about adjusting your diabetes medicine.
Other medications — Some medications may help treat related symptoms, but they do not improve breathing and should not be relied on to treat an asthma attack. These include antihistamines, cough suppressants, mucolytics (medications to thin out mucus in the lungs), expectorants, and other over-the-counter "cold and flu" remedies. Similarly, non-traditional "home remedies" (for example, drinking caffeinated beverages or inhaling steam with peppermint or eucalyptus oil) may provide comfort, but they will not rescue you from the dangers of an asthma attack.
ASTHMA IN PREGNANCY — About 8 percent of pregnant women have asthma. With good asthma treatment during pregnancy, most women can have a normal pregnancy and give birth to a healthy baby. It is essential to keep asthma well controlled during pregnancy to ensure that enough oxygen reaches the growing baby.
If you are considering pregnancy, it's a good idea to talk to your health care provider before you start trying. Your primary care provider can help you make sure that you know as much as possible about your condition and have a treatment plan in place. During pregnancy, you will most likely see your asthma specialist for monitoring as well as your obstetrician or midwife.
More detailed information about asthma during pregnancy is available separately. (See "Patient education: Asthma and pregnancy (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Asthma in adults (The Basics)
Patient education: Avoiding asthma triggers (The Basics)
Patient education: How to use your metered dose inhaler (adults) (The Basics)
Patient education: How to use your dry powder inhaler (adults) (The Basics)
Patient education: Medicines for asthma (The Basics)
Patient education: Asthma and pregnancy (The Basics)
Patient education: Exercise-induced asthma (The Basics)
Patient education: Inhaled corticosteroid medicines (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: How to use a peak flow meter (Beyond the Basics)
Patient education: Inhaler techniques in adults (Beyond the Basics)
Patient education: Asthma and pregnancy (Beyond the Basics)
Patient education: Exercise-induced asthma (Beyond the Basics)
Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)
Patient education: Asthma treatment in children (Beyond the Basics)
Patient education: Asthma inhaler techniques in children (Beyond the Basics)
Patient education: Trigger avoidance in asthma (Beyond the Basics)
Patient education: How to use your soft mist inhaler (adults) (The Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Antileukotriene agents in the management of asthma
Allergen avoidance in the treatment of asthma and allergic rhinitis
An overview of asthma management
Asthma in adolescents and adults: Evaluation and diagnosis
Evaluation of severe asthma in adolescents and adults
Identifying patients at risk for fatal asthma
Natural history of asthma
Severe asthma phenotypes
Acute exacerbations of asthma in adults: Home and office management
Initiating asthma therapy and monitoring in adolescents and adults
Ongoing monitoring and titration of asthma therapies in adolescents and adults
Treatment of severe asthma in adolescents and adults
The following organizations also provide reliable health information.
●The National Library of Medicine
●National Heart, Lung, and Blood Institute
●American Lung Association
●American Academy of Allergy, Asthma, and Immunology
●American College of Allergy, Asthma, and Immunology
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Christopher H Fanta, MD, who contributed to earlier versions of this topic review.
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