The primary objective of asthma treatment is to achieve and maintain control of symptoms, prevent exacerbations and reduce limitations on day-to-day activities. Effective treatment will improve lung function, enhance the overall quality of life for the patient, and reduce the burden on healthcare services. Non-pharmacological treatment of asthma involves avoiding triggers and improving overall respiratory health. Breathing exercises and physical activity can improve lung function, while avoiding triggers such as tobacco smoke, pollen, and animal dander can improve symptoms. Reducing weight can also improve control of asthma in obese patients.
Pharmacological treatment of asthma includes bronchodilators, such as beta-2 agonists and muscarinic antagonists. Examples of short-acting beta2-adrenoceptor agonists (SABA) include salbutamol and terbutaline, while long-acting beta2-adrenoceptor agonists (LABA) include formoterol and salmeterol. Ipratropium bromide is a short-acting muscarinic antagonist (SAMA) used as a bronchodilator. Inhaled corticosteroids (ICS) are used to reduce inflammation in the airways and include beclomethasone, budesonide and fluticasone. Leukotriene receptor antagonists (LTRAs) can also be used as add-on therapy, with montelukast an example. The current best practice in asthma management involves these different classes of drugs and uses a stepwise approach, where patients step up and down as necessary to maintain control of their asthma. This approach is outlined below, with potential add-on options for uncontrolled asthma.
Stepwise approach
Step 1: Recommended for patients with symptoms less than twice per month. Low-dose ICS whenever SABA is required (in adults and children) or low-dose combination ICS/LABA as needed (in adults) are the recommended controller options. Formoterol is the LABA of choice due to quicker onset of action. SABA-only therapy is no longer recommended and can lead to worse clinical outcomes.
Step 2: Recommended for patients with symptoms more than twice per month but less than daily. The preferred controller is daily low-dose ICS plus as required SABA (in adults and children) or as required low-dose ICS/LABA combination. Other options include a LTRA where a patient may not tolerate ICS, or the patient has concomitant allergic rhinitis.
Step 3: Recommended for patients that have symptoms most days. In adults, low-dose ICS/LABA maintenance plus as required SABA or low-dose ICS/LABA maintenance and reliever therapy (MART) is recommended as treatment. In children, the recommendation is for medium-dose ICS plus as required SABA or low-dose combination ICS/LABA plus as required SABA. A MART treatment is recommended for adults with moderate-to-severe asthma. This plan offers many benefits including flexible dosing to address symptoms, reduces chance of SABA reliever overuse, lowers overall steroid load, and reduces rate of exacerbations.
Step 4: Recommended for patients that have symptoms most days or have low lung function. The recommended treatment is low-to-medium-dose ICS/LABA MART (in adults) or medium-dose ICS/LABA maintenance plus as required SABA (in adults and children).
Breathing exercises and physical activity can improve lung function while avoiding triggers such as tobacco, smoke, pollen, and animal dander can improve symptoms. Reducing weight can also improve control of asthma in obese patients
Step 5: For patients who have persistent symptoms and exacerbations despite correct inhaler technique and adherence with step 4 treatment. These patients should be referred for phenotypic investigations and add-on treatment options explored.
Long-acting muscarinic antagonist (LAMA) therapy is indicated as add-on maintenance bronchodilator therapy for patients with severe asthma who have experienced one or more exacerbations in the preceding 12 months, despite using high-dose ICS and LABA. Tiotropium and glycopyrronium are examples of two LAMAs used for this purpose. Other medications that may be considered as add-on therapy after specialist review include high-dose ICS, oral theophylline, and oral corticosteroids. Monoclonal antibody treatment options may be considered by specialists for treating patients with severe, uncontrolled asthma.
Pharmacists play a pivotal role in asthma management due to their expertise in drug management, accessibility, and frequent interactions with patient. Pharmacists are ideally placed to provide education to patients to improve their knowledge about asthma, their triggers, understanding their prescribed medication, and the importance of adherence to their pharmacological treatment. Furthermore, pharmacists can teach proper inhaler technique to patients and counsel on the importance of this. Pharmacists can also assess the medication needs of a patient and collaborate with other health professionals to individualise an asthma management plan for a patient. By conducting medication reviews, assessing symptoms, optimising a medication regimen, and provide ongoing support, pharmacists can empower patients to achieve and maintain optimal asthma control and improve their quality of life.
References on request
