There are a variety of medications for Asthma, that are divided into 2 general types:
- “Rescue” (or “Reliever”) Medications: These relax bronchial muscles that become tight. They work quickly, make you feel better. but don’t last long. You have to keep using them. Use these when you feel symptoms.
- “Controller” Medications: These don’t have an immediate effect. You use them on a regular basis, every day. They keep asthma under control by decreasing swelling and mucus in the bronchi, so you always feel well, without the need for “Rescue” meds.
Most of the medications are inhaled. There are lots of types, with lots of different brands, and each brand gets used in a different way. Many patients use them wrong; be sure to ask your pharmacist or provider for a good explanation.
The medications are given for treatment; see the very end for how they might sometimes be used diagnostically. The following are the major types, with some examples of generic names (you need to read the fine print on the inhaler to locate generic names).
1. Albuterol, inhaled (usually). Levo-albuterol works the same. It’s usually used every 3-4 hours maximum, but in a life-threatening situation, can be given 1 puff per minute while ambulance is en route. Various brand names include Ventolin®, Pro-Air®, Proventil®, etc.
2. Ipratropium, inhaled. May be combined with Albuterol (brand name product Combivent®).
3. Epinephrine (injected by Epi-Pen®). Not for asthma, but will work if it’s life-threatening.
1. Inhaled corticosteroids (“steroids“). Some generic names include Fluticasone, Budesonide, Beclomethasone, Mometasone, Flunisolide, Ciclesonide. Don’t forget, these generic names are often in fine print or parentheses; the big name on the box is the brand name, which I try not to use to avoid commercial bias. Also note that whereas systemic steroids (oral, injected) can be dangerous over the long run, inhaled steroids are completely safe (unless in very high doses).
2. Inhaled “long-acting beta-agonists” (LABA’s). Only used when combined together with an inhaled steroid. Some generic names include Salmeterol, Formoterol, Olodaterol, Indacaterol, Vilanterol, Arfomoterol.
3. Inhaled “long-acting muscarinic-antagonists” (“LAMAs”) [or “anticholinergics”]. Some generic names include Tiotropium, Aclidinium, Umeclidinium. If one of these is combined with a LABA, do not use an inhaled steroid combination product that also includes a LABA.
4. Montelukast (Singulair®). A once-a-day oral pill (known as a leukotriene inhibitor).
5. Other controller medications exist as well, including newer ones which are very expensive, have certain risks, and in my mind should only be given by an asthma specialist (usually a pulmonologist). They’re heavily advertised.
Medications NEVER to use (in my opinion)
1. Primatene Mist®. This is inhaled epinephrine, which works for a very short period, leading people to use it over and over, when it can be dangerous. It should never be used by anyone at risk of heart disease. Unfortunately, it’s been grandfathered in over-the-counter or behind-the-counter (still without a prescription. Inhaled Albuterol (see Resuce Medications above) is much better.
2. Anything with Ephedrine as an ingredient. It’s useless, potentially harmful.
3. Racemic Epinephrine. When used as a nebulized solution, it’s dangerous like Primatene Mist® (#1 above). When used as Asthmanefrin®, an over-the-counter inhaled product, it doesn’t reach the lungs and is thus useless (but may have a placebo effect).
Using Asthma Medications Diagnostically
Some patients only get asthma symptoms (cough, shortness of breath) when they exercise, or in certain situations (like the cold, etc.). So if we listen to their lungs, or perform pulmonary function testing, when they’re at rest in our office, we won’t find anything abnormal. I resort to one of the following strategies:
1. Have them use an Albuterol inhaler 15-30 minutes before an anticipated exertion of situation that may give them symptoms (like climbing stairs, etc.). If that consistently prevents symptoms, we have a diagnosis.
2. Have them use a controller medication daily, to see if their symptoms stop occurring. The easiest is Montelukast, just one pill per day. But inhaled steroids are stronger, so if Montelukast doesn’t help, we won’t know if it’s wrong diagnosis, or inadequate treatment.
Some patients with a chronic cough really have asthma, even though the lungs sound clear (no wheeze, etc.). This can be diagnosed by pulmonary function tests, but I often just give them Montelukast, & tell them to use Albuterol also every 3-4 hours, to see if the cough disappears. If so, I have them stop treatment, to see if it returns.