Asthma: Diagnosis and Management ____________________________________________________________
Corticosteroids The most common group of anti-inflammatory medications is oral corticosteroids. Oral corticosteroids are powerful anti- inflammatory medications. They are easy to administer and offer dramatic reversal of symptoms during life-threatening asthma situations. Although some corticosteroids take a few hours to work, their protection is long-lasting. Oral corticoste- roids can be used for a brief period to gain control of asthma before moving to other long-term treatments that have fewer side effects, such as inhaled corticosteroids. Although reports about side effects from steroids may concern some patients with asthma, oral or inhaled corticosteroids can be a promis- ing remedy for severe, uncontrolled asthma [9; 11]. Patients and/or parents may require reassurance that these are not the same class of steroids used illegally by athletes. Corticosteroids used in the treatment of asthma are adrenal hormones. Oral corticosteroid medications are absorbed into the circulatory system and are distributed throughout the body. In the lungs, they prevent the development of airway edema. Significant amounts of corticosteroids for prolonged periods can adversely affect other organ systems, such as bones and skin [9; 11]. Severe asthma may require higher doses for longer periods, which may then be tapered off over a period of one to three weeks. Patients should be reminded that it is dangerous to abruptly discontinue oral corticosteroids. Corticosteroids are usually taken upon awakening, mimicking the body’s natural steroid production schedule. Night-time symptoms may be managed with split doses taken in the morning and at night [9; 35]. A major disadvantage of oral corticosteroids is the array of negative side effects associated with taking large doses over long periods of time. Because these medications enter the cir- culatory system, there is potential for damage to other organs. If taken for severe asthma, patients should be diligent about identifying and reporting any side effects [9; 11]. Inhaled corticosteroids are the most consistently effective long-term control medication for both children and adults with persistent asthma, and the NAEPP recommends the use of inhaled corticosteroids, either alone or in combination, for most individuals with persistent asthma [9; 10]. Inhaled corticosteroid therapy concentrates on reducing airway edema and improves results obtained from bronchodilators while eliminating extraneous effects to other systems. A beta 2 agonist may be prescribed in conjunction with an inhaled corticosteroid; the beta 2 agonist is used first to unblock airways so the corticosteroid can penetrate deeper. Common inhaled corticosteroids include beclomethasone, flunisolide, triamcino- lone, and budesonide (available in a dry powder inhaler) [11]. Corticosteroids are often combined with formoterol in a single inhaler for ease of use and better asthma control [9]. In 2023, the FDA approved an albuterol/budesonide combination inhaler; this is the first inhaler combining both a corticosteroid and a beta 2 agonist [53].
In 2010, the FDA required a boxed warning for drugs that include both a long-acting beta 2 agonist and inhaled corti- costeroid due to an increased risk of severe exacerbation of asthma symptoms that led to hospitalization and death in some patients using these drugs for the treatment of asthma. In 2011, the FDA required post-market safety trials for these drugs [36]. In 2017, clinical trials were concluded, and it was determined that there was no significant increase of serious risks in patients taking beta 2 agonists in conjunction with an inhaled corticosteroid; however, it was noted that taking a long- acting beta 2 agonist alone to treat asthma without an inhaled corticosteroid to treat lung inflammation increases the risk of asthma-related death. The boxed warning, therefore, only pertains to single-ingredient long-acting beta 2 agonists [37]. Patients who take inhaled corticosteroids may complain about the lack of immediate symptom relief and cite it as a reason for not taking the medication. It is important to stress the long-term benefits when discussing this therapy with patients. Although risks of corticosteroid side effects are greatly reduced with inhalers, they do exist; prolonged use of high doses can increase chances for the same types of unpleasant symptoms attributed to the oral or injected forms [9; 11]. The doses of the inhaled corticosteroid must be very high to equal the risk of side effects associated with oral corticosteroids. Two more common adverse reactions to inhaled corticosteroids are throat irritation and candidiasis. Candidiasis can develop when a patient is taking antibiotic medications in addition to the corticosteroid inhaler or if other medical problems, such as diabetes, exist. To prevent candidiasis, advise patients to rinse their mouths after each inhaler treatment and to gargle with warm water to remove any medication left in the throat. The use of a spacer may also be advisable, as it should ensure that medicine particles are delivered to the lungs rather than to the mouth and throat [9; 11]. Mast Cell Stabilizers Mast cell stabilizers or inhibitors are considered mild-to- moderate anti-inflammatory agents and are most effective in the treatment and prevention of exercise- or allergen-induced asthma. Mast cell stabilizers interfere with the inflammatory process by stabilizing mast cell membranes and inhibiting the activation and release of mediators such as histamine and leu- kotrienes. They may also restrain the development of early and late bronchoconstriction responses to inhaled antigens. Mast cell stabilizers used to treat asthma are generally administered by inhalation, but eye and nasal drops are also available. One mast cell inhibitor available for the long-term management of asthma is cromolyn. However, this medication is consid- ered less effective than inhaled steroids in the treatment of moderate-to-severe persistent asthma in adults and children and is not effective for immediate relief of acute asthma attacks [11; 35]. The NAEPP recommends that they may be considered for treatment of persistent asthma for patients of all ages, but their use is not preferred [9; 10].
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MDVT1726
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