Listed below are the treatment options the National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma recommends for severe asthma patients in different age groups.
Several types of standard asthma medicines are recommended to control asthma over long periods of time (long-term controller medicines). These are taken regularly to reduce asthma symptoms and prevent asthma attacks.
Because asthma patients’ airways are always inflamed, they need medicines to reduce inflammation, which decreases airway swelling and makes airways less sensitive to asthma triggers. Corticosteroids are the most powerful and most important of these anti-inflammatory medicines. Patients with severe asthma will require high doses of inhaled corticosteroids to reduce airway inflammation, but some will still have trouble controlling this inflammation along with their asthma symptoms. According to the National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma most of these patients will also need a medicine called a long-acting beta-agonist.
Patients with severe asthma are advised to treat their asthma not only with a high-dose of inhaled corticosteroid, but also with a long-acting beta-agonist medicine. This type of medicine reduces airway tightening for up to 12 hours by relaxing the muscles wrapped around certain airways, and is called a bronchodilator. These medicines are inhaled and should be taken with an anti-inflammatory medicine to control asthma symptoms. These can be prescribed for patients of all ages.
*The treatment of asthma with inhaled corticosteroids can be prescribed for patients of all ages, while long-acting beta-agonists are approved for children older than 4 years.
In some cases, a severe asthma patient requires long-term oral corticosteroids to control his or her asthma, possibly in addition to an inhaled corticosteroid and a long-acting beta-agonist. Oral corticosteroid medicines are not preferred for controlling asthma long-term because of the increased risk of side-effects. The National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma recommends that doctors prescribe the lowest possible dose of oral corticosteroids to patients and attempt to scale back dosage in favor of high-dose inhaled corticosteroids. The most commonly used oral corticosteroid is known as prednisone. This treatment can be used in patients of all ages.
Leukotrienes are natural chemicals in the body that cause airway muscles to tighten, stimulate mucus production, and increase inflammation. Leukotriene modifier medicines stop the action of leukotrienes to make breathing easier and prevent asthma symptoms. Their names include: zileuton, zafirlukast, montelukast. These can be used for patients of all ages, either by themselves or with other asthma controller medicines. In general leukotriene modifier medicines are not as powerful as long-acting beta-agonists at relaxing airway muscles or as corticosteroids at reducing inflammation. However, some patients respond very well to leukotriene modifiers.
Anticholinergic medications reduce mucus production and airway irritability, have modest bronchodilating ability, and can be used with other asthma controllers. Short acting ipratropium, such as Atrovent, or long-acting tiotropium, such as Spiriva, are examples. These medicines are delivered by inhalation.
This bronchodilator is used to control asthma and patients can only take it orally. They must take it daily and it must remain at a constant level in the blood stream to be effective. If too much of it is in the blood stream, it can be dangerous, so the doctor will do regular blood tests to check this. It can help with nighttime symptoms, but should be used in addition to anti-inflammatory medicines like inhaled corticosteroids. Theophylline can be prescribed for patients age 5 and up in place of or along with other asthma controllers. Because of potential side effects, theophylline is not a preferred treatment.
Patients with severe asthma will likely also need rescue medicines that quickly relieve asthma symptoms. Patients use short-acting beta agonists for quick relief of asthma symptoms. If a patient uses these at least several times daily, he or she might have poorly controlled asthma, or might have underlying severe asthma.
Ipratropium (Atrovent inhalers) also can be used as a rescue medication, typically together with a short-acting beta-agonist, to help reduce asthma symptoms, including those from mucus production and contraction of airway muscle.
Short-term oral corticosteroids
These medicines can be prescribed in the event of a severe asthma attack. When they are prescribed in high doses, short-term, it is called an oral steroid “burst.”
Anti-IgE therapy can be used to treat patients with severe allergic asthma. It targets an antibody, or protein, called Immunoglobulin E (IgE) found in patients’ bodies. One end of the IgE molecule binds to the surface of mast cells and basophils, cells that contain histamine, while the other end binds to those allergens to which the person is sensitive. When an allergen binds to the IgE on the surface of these cells, the cells release substances that can cause inflammation, mucus production and bronchoconstriction, causing the patient to experience asthma symptoms.
Anti-IgE therapy (Xolair, omalizumab) works by blocking IgE from binding to these cells so that an allergen cannot trigger them to release substances that would trigger asthma symptoms. This medication is recommended for patients with severe allergic asthma. Patients will still need their other long-term asthma medicines, but this medicine may prevent allergic asthma symptoms from starting, reducing the number of asthma attacks. This medication is administered by a healthcare professional and is injected under the skin every two or four weeks.
Bronchial Thermoplasty (BT)
Recently, the Food and Drug Administration (FDA) approved bronchial thermoplasty (BT) for patients with severe persistent asthma. Asthma is characterized by chronic airway obstruction and inflammation, which causes the smooth muscle cells in the airways to increase in size and numbers and to tighten or constrict the airway. This reduces airflow and makes breathing difficult. Bronchial thermoplasty works to make a patient’s breathing easier by decreasing the amount of muscle around the airways, which increases airflow.
All of these treatments and medicines are options that should be discussed with and prescribed by the doctor depending on a patient’s individual needs.
Even with these available medicines, severe asthma patients still struggle to live a normal quality of life. Patients should work with their doctors to have their level of control assessed as they receive treatment and to see if any changes need to be made. Patients likely will need a specialist to talk to about treatment options. Patients with severe asthma will most likely need to monitor and assess their asthma more frequently than others with “regular” asthma. It is recommended that severe asthma patients have an asthma action plan in place.
If you are having difficulty getting an asthma or allergy service or procedure covered by your insurance that is recommended by your doctor, click here for more information. Feel free to also download our Patient Advocacy Support Letter for Full Coverage of BT.