Asthma Medications: Complete Guide to Inhalers & Treatment

What Are the Main Types of Asthma Medications?

Asthma medications fall into two main categories: controller medications (taken daily to prevent symptoms by reducing inflammation) and reliever medications (used as needed for quick relief during symptoms or attacks). Most people with persistent asthma need both types of medications to achieve good control.

Understanding the different types of asthma medications is essential for managing your condition effectively. Asthma is a chronic inflammatory disease of the airways, and treatment aims to both control the underlying inflammation and provide relief when symptoms occur. The choice of medications depends on the severity of your asthma, how often you have symptoms, and how well your current treatment is working.

The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to treatment, starting with the mildest effective therapy and increasing treatment if control is not achieved. This personalized approach ensures that you receive the right level of treatment for your individual needs while minimizing potential side effects.

Modern asthma treatment has evolved significantly over the past decades. Today, we have a wide range of medications that can help most people with asthma lead normal, active lives. The key is finding the right combination of medications and using them correctly. Working closely with your healthcare provider to develop a personalized asthma action plan is crucial for optimal management.

Controller Medications (Preventers)

Controller medications are taken daily to prevent asthma symptoms by reducing the inflammation in your airways. These medications work gradually over time and need to be taken consistently, even when you feel well. The most important controller medications are inhaled corticosteroids (ICS), which remain the cornerstone of asthma treatment for people with persistent symptoms.

It's essential to understand that controller medications don't provide immediate relief during an asthma attack. Their purpose is to reduce airway inflammation and hypersensitivity over time, making your airways less likely to react to triggers. Most people notice improvement within a few days to weeks of starting controller therapy, but maximum benefit may take several weeks to achieve.

Reliever Medications (Rescue Inhalers)

Reliever medications provide quick relief during asthma symptoms or attacks by relaxing the muscles around your airways. These medications work within minutes and are essential for managing acute symptoms. Short-acting beta-2 agonists (SABAs) like salbutamol (albuterol) are the most commonly used reliever medications.

While reliever medications are effective for quick symptom relief, relying on them too frequently indicates that your asthma is not well controlled. If you need to use your reliever inhaler more than twice a week (apart from before exercise), you should speak with your healthcare provider about adjusting your controller therapy.

How Do Inhaled Corticosteroids Work?

Inhaled corticosteroids (ICS) are the most effective controller medications for persistent asthma. They work by reducing inflammation in the airways, healing irritated tissue, and decreasing the production of mucus. ICS must be taken daily for several weeks to achieve full effect, and they can be used safely for many years.

Inhaled corticosteroids work by mimicking the effects of natural cortisol, a hormone produced by your adrenal glands that helps regulate inflammation in the body. When you inhale these medications, they are deposited directly in your airways where they reduce swelling, decrease mucus production, and make your airways less sensitive to triggers. This targeted delivery means that most of the medication works where it's needed, with minimal absorption into the rest of your body.

The anti-inflammatory effects of ICS are broad and powerful. They reduce the number of inflammatory cells in the airways, decrease the production of inflammatory chemicals (cytokines and chemokines), reduce swelling of the airway lining, and decrease mucus secretion. These combined effects lead to reduced airway hyperresponsiveness – meaning your airways become less likely to constrict in response to triggers like allergens, cold air, or exercise.

Unlike oral corticosteroids, which can cause significant side effects when used long-term, inhaled corticosteroids have an excellent safety profile at recommended doses. This is because the medication is delivered directly to the lungs, and modern ICS formulations are designed to be rapidly metabolized if absorbed into the bloodstream. This allows for effective local treatment with minimal systemic effects.

It's important to understand that ICS are not rescue medications – they won't help during an acute asthma attack. Their benefit comes from consistent daily use, which gradually reduces inflammation and makes your airways less reactive over time. Most people begin to notice improvement within the first week or two of treatment, but maximum benefit may take 1-3 months to achieve.

Examples of Inhaled Corticosteroids

Several inhaled corticosteroids are available, and they come in different formulations and devices. The choice of medication often depends on factors like dosing frequency, device preference, and cost. Common active ingredients include:

• Beclomethasone: One of the older ICS medications, available in various inhaler devices
• Budesonide: Available as dry powder inhaler and nebulizer solution, often used in combination products
• Fluticasone: Available in multiple formulations (propionate and furoate), commonly used in combination inhalers
• Ciclesonide: A pro-drug that is activated in the lungs, potentially causing fewer local side effects
• Mometasone: Available in dry powder form, used once or twice daily

Side Effects of Inhaled Corticosteroids

When used at recommended doses, inhaled corticosteroids have minimal systemic side effects. However, some local side effects can occur because some of the medication deposits in the mouth and throat rather than reaching the lungs. The most common side effects include:

• Hoarseness (dysphonia): Caused by effects on the vocal cords
• Oral thrush (candidiasis): A fungal infection in the mouth that appears as white patches
• Sore throat or mouth: Local irritation from the medication

In children, high doses of inhaled corticosteroids may slightly affect growth velocity, though studies suggest that final adult height is minimally affected. Children using regular inhaled corticosteroids should have their height monitored one to two times per year. The benefits of good asthma control generally outweigh this small risk, but using the lowest effective dose is always recommended.

What Are Bronchodilator Medications?

Bronchodilators are medications that relax the muscles around the airways, causing them to widen (dilate) and making it easier to breathe. They are used both for quick relief of acute symptoms and for long-term maintenance therapy. The main types are beta-2 agonists (short-acting and long-acting) and anticholinergic medications.

Bronchodilator medications work by targeting the smooth muscle that surrounds the airways. In asthma, this muscle can contract excessively, causing the airways to narrow and making breathing difficult. Bronchodilators reverse this muscle contraction, opening up the airways and improving airflow. While they don't address the underlying inflammation like corticosteroids do, they provide essential relief from symptoms like wheezing, chest tightness, and shortness of breath.

The rapid relief provided by bronchodilators makes them invaluable during asthma attacks and for preventing exercise-induced symptoms. However, it's important to understand that bronchodilators alone don't treat the inflammation that underlies asthma. For this reason, except for people with very mild, intermittent asthma, bronchodilators should typically be used in combination with inhaled corticosteroids rather than as sole therapy.

Short-Acting Beta-2 Agonists (SABA)

Short-acting beta-2 agonists are the most commonly used reliever medications for asthma. They work within 1-5 minutes by stimulating beta-2 receptors on airway smooth muscle cells, causing the muscle to relax. Their effects last for 4-6 hours. These medications are also known as "rescue inhalers" because of their rapid action during acute symptoms.

SABAs like salbutamol (albuterol) and terbutaline are typically used on an as-needed basis for quick relief of symptoms or before exercise to prevent exercise-induced bronchoconstriction. They can also be used during severe asthma attacks while waiting for emergency medical care. Most people with asthma should carry their SABA inhaler with them at all times.

While SABAs are highly effective for symptom relief, overreliance on them can be dangerous. If you find yourself needing your SABA inhaler more than twice a week (aside from before exercise), or if you're using more than one canister per month, your asthma is not well controlled. This is an important signal to speak with your healthcare provider about adjusting your controller therapy.

Long-Acting Beta-2 Agonists (LABA)

Long-acting beta-2 agonists provide bronchodilation for up to 12 hours. They are used as maintenance therapy in combination with inhaled corticosteroids, not as rescue medication. LABAs like formoterol and salmeterol help control symptoms, especially at night, and reduce the frequency of asthma attacks.

An important safety consideration is that LABAs should never be used alone in asthma – they must always be combined with an inhaled corticosteroid. Using LABAs without anti-inflammatory therapy has been associated with an increased risk of severe asthma attacks. For this reason, LABAs are most commonly prescribed as combination inhalers that include both a LABA and an ICS in the same device.

Formoterol has a faster onset of action than salmeterol (working within 1-3 minutes compared to 15-20 minutes), making combination inhalers containing formoterol suitable for both maintenance and reliever therapy (MART – Maintenance And Reliever Therapy) in some patients.

Common Side Effects of Beta-2 Agonists

Beta-2 agonists can cause side effects because they affect beta-2 receptors in other parts of the body, not just the airways. These side effects are usually mild and temporary, often improving with continued use. Common side effects include:

• Palpitations (rapid or irregular heartbeat): Due to effects on the heart
• Tremor: Shakiness, particularly in the hands
• Headache: Usually mild and temporary
• Muscle cramps: Particularly in the arms, legs, or fingers
• Feeling jittery or nervous: More common with higher doses

Anticholinergic (Antimuscarinic) Medications

Anticholinergic medications work by blocking acetylcholine, a neurotransmitter that causes airway smooth muscle to contract. By blocking this signal, these medications help the airways stay open. They work through a different mechanism than beta-2 agonists and can provide additional bronchodilation when used together.

Long-acting anticholinergics like tiotropium are increasingly used as add-on therapy for people whose asthma is not well controlled with inhaled corticosteroids and long-acting beta-2 agonists. They are also commonly used in combination inhalers that contain all three types of medication (ICS/LABA/LAMA – inhaled corticosteroid/long-acting beta-2 agonist/long-acting muscarinic antagonist).

Short-acting anticholinergics like ipratropium are sometimes used in acute asthma attacks, typically in combination with a SABA, especially in emergency department settings. They provide additional bronchodilation and may be particularly helpful in severe attacks.

The most common side effect of anticholinergic inhalers is dry mouth. People with certain conditions, such as enlarged prostate, should use these medications with caution as they can make urination more difficult.

What Are Combination Inhalers?

Combination inhalers contain two or three different medications in a single device, typically an inhaled corticosteroid with a long-acting bronchodilator. They simplify treatment by reducing the number of inhalers needed, improve adherence to therapy, and ensure that anti-inflammatory medication is always taken alongside bronchodilators.

Combination inhalers have become the most commonly prescribed form of maintenance therapy for persistent asthma. By combining medications in a single device, they offer several important advantages. First, they simplify treatment regimens – using one inhaler twice daily is much simpler than using two or three different inhalers at different times. This simplicity improves adherence, which is crucial for good asthma control.

Second, combination inhalers ensure that patients always receive their anti-inflammatory medication when they use their bronchodilator. This is important because the benefits of bronchodilators can mask poor underlying control, and using LABAs without corticosteroids has been associated with increased risks. With a combination inhaler, this risk is eliminated.

The most common type of combination inhaler contains an inhaled corticosteroid (ICS) and a long-acting beta-2 agonist (LABA). Examples include budesonide/formoterol, fluticasone/salmeterol, and fluticasone/vilanterol. These are typically used twice daily for maintenance therapy, though some formulations allow for once-daily dosing.

Newer triple combination inhalers contain three medications: an ICS, a LABA, and a long-acting muscarinic antagonist (LAMA). These are particularly useful for people with more severe asthma who need additional bronchodilation beyond what ICS/LABA combinations provide. Examples include beclomethasone/formoterol/glycopyrronium and mometasone/indacaterol/glycopyrronium.

How Do I Use an Inhaler Correctly?

Proper inhaler technique is essential for medication to reach your lungs effectively. For metered-dose inhalers (MDI), shake well, exhale fully, press while inhaling slowly for 3-5 seconds, and hold your breath for 10 seconds. For dry powder inhalers (DPI), do not shake, exhale away from the device, and inhale quickly and deeply. Using a spacer with MDI improves drug delivery.

Research shows that up to 90% of people with asthma make at least one error when using their inhaler, and these errors can significantly reduce the amount of medication reaching the lungs. Even small improvements in technique can dramatically improve asthma control. For this reason, your healthcare provider should check your inhaler technique at every visit and provide training when needed.

Different types of inhalers require different techniques. The two main categories are metered-dose inhalers (MDI), which use a propellant to deliver medication as a spray, and dry powder inhalers (DPI), which require you to generate enough airflow to draw the powder into your lungs. Understanding the correct technique for your specific device is crucial.

Using a Metered-Dose Inhaler (MDI)

Metered-dose inhalers deliver medication as a fine mist using a propellant. The key challenge is coordinating the pressing of the canister with your inhalation. Follow these steps for optimal technique:

1. Remove the cap and shake the inhaler vigorously for 5 seconds
2. Exhale fully away from the inhaler to empty your lungs
3. Hold the inhaler upright with your index finger on top and thumb supporting the bottom
4. Place the mouthpiece between your teeth and close your lips around it (or hold 2-3 cm from open mouth)
5. Start breathing in slowly and press down on the canister
6. Continue inhaling slowly and deeply for 3-5 seconds
7. Remove the inhaler and hold your breath for 10 seconds (or as long as comfortable)
8. Wait 30-60 seconds before taking a second puff if needed
9. Rinse your mouth with water after using corticosteroid inhalers

Using a Spacer Device

A spacer (also called a holding chamber or aerochamber) is a tube-like device that attaches to your MDI. It makes the medication easier to inhale by eliminating the need to coordinate pressing and breathing – you can breathe at your own pace after activating the inhaler. Spacers also reduce the amount of medication that deposits in your mouth and throat, which decreases side effects from corticosteroids.

Spacers are particularly recommended for children, elderly patients, anyone who has difficulty coordinating their inhaler use, and anyone using inhaled corticosteroids. When using a spacer, shake the inhaler, attach it to the spacer, press once to release medication into the chamber, then breathe in slowly and deeply through the mouthpiece.

Using a Dry Powder Inhaler (DPI)

Dry powder inhalers deliver medication as a fine powder that you inhale. Unlike MDIs, they are breath-activated and don't require coordination between pressing and inhaling. However, they do require you to breathe in quickly and forcefully to generate enough airflow to draw the powder into your lungs. Key points for DPI use:

• Do not shake dry powder inhalers
• Load the dose according to your device's specific instructions
• Exhale away from the inhaler (breathing into the device can moisten the powder)
• Inhale quickly and deeply through the mouthpiece
• Hold your breath for 10 seconds
• Do not use a spacer with dry powder inhalers

Children and Inhaler Use

Children can begin using dry powder inhalers when they can handle the device themselves and generate sufficient inspiratory flow, typically around age 5-6. Before this age, children usually need MDIs with spacers and masks. Even older children should be supervised and have their technique checked regularly.

For young children, an adult should help with medication administration regardless of the device type. A healthcare provider or pharmacist can demonstrate proper technique and help choose the most appropriate device for your child's age and abilities.

What Other Medications Are Used for Asthma?

Beyond inhaled medications, asthma treatment may include leukotriene receptor antagonists (oral tablets), oral corticosteroids (for severe attacks), theophylline, and biologic therapies for severe, uncontrolled asthma. The choice of additional medications depends on asthma severity and response to standard treatment.

While inhaled medications form the backbone of asthma treatment, some patients require additional therapies to achieve good control. These medications work through different mechanisms and can be valuable additions to standard inhaler therapy. Your healthcare provider will recommend additional medications based on your specific situation and response to treatment.

Leukotriene Receptor Antagonists

Leukotrienes are inflammatory chemicals released by certain cells in the airways that contribute to asthma symptoms. Leukotriene receptor antagonists, such as montelukast, block the effects of these chemicals and help reduce inflammation and bronchoconstriction. These medications are taken as daily tablets and can be particularly useful for patients with allergic asthma or exercise-induced symptoms.

Leukotriene modifiers are not as effective as inhaled corticosteroids for controlling asthma but can be useful as add-on therapy. They're available as tablets to swallow, chewable tablets, or granules that can be mixed with food (for children). Common side effects include headache and upper respiratory infections.

Oral Corticosteroids

Oral corticosteroids (like prednisolone or prednisone) are potent anti-inflammatory medications used for severe asthma attacks or when inhaled medications are not providing adequate control. They work systemically throughout the body and can quickly reduce severe airway inflammation. Short courses of oral steroids may be prescribed during asthma exacerbations.

Long-term use of oral corticosteroids can cause significant side effects including weight gain, high blood pressure, osteoporosis, diabetes, cataracts, and skin thinning. For this reason, they are reserved for situations where other treatments are insufficient, and the goal is always to use the lowest effective dose for the shortest possible time.

Biologic Therapies

Biologic medications represent a major advance in the treatment of severe asthma. These are targeted therapies given by injection that block specific components of the inflammatory pathway. They are reserved for patients with severe asthma who remain uncontrolled despite high-dose inhaled corticosteroids and other medications, or who require frequent courses of oral corticosteroids.

Different biologic medications target different aspects of asthma inflammation:

• Omalizumab: Targets IgE antibodies in allergic asthma
• Mepolizumab, Reslizumab, Benralizumab: Target eosinophils (a type of white blood cell involved in allergic inflammation)
• Dupilumab: Blocks IL-4 and IL-13, inflammatory signals involved in type 2 inflammation
• Tezepelumab: Blocks TSLP, an inflammatory signal released by airway cells

These medications are given as injections, typically every 2-8 weeks depending on the specific drug. Your doctor can determine if a biologic medication would be appropriate for you based on blood tests, your asthma phenotype, and your response to other treatments.

Theophylline

Theophylline is an older medication that causes bronchodilation and has some anti-inflammatory effects. It's taken as tablets and can be used as add-on therapy for difficult-to-control asthma. However, theophylline has a narrow therapeutic range, meaning there's a small difference between an effective dose and a toxic dose. Blood levels must be monitored, and the medication can interact with many other drugs, limiting its use in modern asthma management.

Can I Use Asthma Medications During Pregnancy?

Yes, most asthma medications are safe during pregnancy and breastfeeding. Maintaining good asthma control during pregnancy is crucial because uncontrolled asthma poses greater risks to both mother and baby than the medications themselves. Never stop your asthma medications without consulting your doctor when you become pregnant.

Pregnancy is a time when many women worry about taking any medications. However, for asthma, the evidence is clear: uncontrolled asthma during pregnancy is associated with significantly increased risks of complications including preeclampsia, premature birth, low birth weight, and increased cesarean delivery rates. Good asthma control benefits both the mother and the developing baby.

The major asthma medications have extensive safety data in pregnancy. Inhaled corticosteroids, particularly budesonide which has the most safety data, are considered safe to use throughout pregnancy. Short-acting beta-2 agonists like salbutamol have been used safely in millions of pregnancies. Long-acting beta-2 agonists and most other asthma medications are also considered acceptable during pregnancy.

Some women experience changes in their asthma during pregnancy – about one-third improve, one-third stay the same, and one-third worsen. It's important to monitor your asthma closely during pregnancy and work with your healthcare provider to adjust medications if needed. Regular check-ups and maintaining an asthma action plan are especially important during this time.

When Should I Seek Emergency Care for Asthma?

Seek emergency medical care immediately if your reliever inhaler doesn't provide relief within 10-15 minutes, you have severe difficulty breathing, your lips or fingernails turn blue, you can't speak in full sentences, or you feel your chest muscles straining to breathe. Use your reliever inhaler while waiting for emergency services.

Recognizing a severe asthma attack and seeking timely emergency care can be lifesaving. While most asthma attacks can be managed at home with your action plan and medications, some attacks are severe enough to require emergency medical treatment. Learning to recognize the warning signs of a severe attack is crucial.

While waiting for emergency services, continue using your reliever inhaler – you can take puffs every few minutes during a severe attack. Sit upright (do not lie down) to help your breathing. Try to stay calm, as panic can worsen breathing difficulties. If you have an asthma action plan from your doctor, follow its instructions for severe attacks.

Treatment in the emergency department may include nebulized bronchodilators (both SABA and anticholinergics), oral or intravenous corticosteroids, oxygen therapy through a mask, and in severe cases, other interventions. After emergency treatment, it's important to follow up with your regular healthcare provider to review your asthma management and prevent future severe attacks.

Can Athletes Use Asthma Medications?

Most asthma medications are permitted in competitive sports when used at therapeutic doses. However, some medications require notification or a Therapeutic Use Exemption (TUE). Athletes should check current anti-doping regulations and consult their doctor about permitted treatments.

Exercise-induced asthma is common among athletes, and having asthma should not prevent anyone from participating in sports. Many elite athletes successfully compete while managing their asthma with appropriate medications. However, athletes competing at high levels need to be aware of anti-doping regulations that apply to some asthma medications.

Inhaled corticosteroids and most inhaled bronchodilators are permitted in competition when used at therapeutic doses. However, some medications may require notification or documentation. For example, in some sports federations, terbutaline requires a Therapeutic Use Exemption. Beta-2 agonists taken orally or by injection (rather than inhaled) are generally prohibited.

Athletes should consult current regulations from their relevant sports authority (such as the World Anti-Doping Agency - WADA) and work with a sports medicine physician to ensure their asthma treatment plan is compliant with anti-doping rules while maintaining good asthma control.