Synthetic versions of hormones produced in the adrenal glands, corticosteroids are the most powerful anti-inflammatory medications now available for treating asthma. In inhaled form, they are used exclusively for long-term control; they are not very effective for acute symptoms. Systemic corticosteroids taken by mouth as pills or liquid, or injected, are sometimes of value to get asthma quickly under control when a child is beginning long-term asthma therapy. Inhaled corticosteroids are the agents preferred and recommended as first-line treatment of chronic asthma by various asthma expert panels that publish guidelines on the proper treatment of asthma. They are available in various forms and different dosage forms, which make them convenient for patients to take, such as an aerosol in a metered-dose inhaler (MDI), a dry powder inhaler (DPI), and a liquid form that can be used in a nebulizer for small children.
These compounds act by decreasing the effects of an inflammatory chemical made by the body known as leukotrienes. The 2 leukotriene modifiers currently in use, montelukast and zafirlukast, are used as control medications. They have only mild to moderate beneficial effects at best but are very safe. They are taken in pill form; chewable and sprinkle forms are available for young children.
Medications in the beta2-agonist class work by relaxing the muscles that wrap around the bronchi of the lungs and tend to squeeze down and narrow the airways in those who have asthma. The short-acting forms of beta2-agonists, such as albuterol, are used as first-line agents for relief of asthma in all patients with asthma. Long-acting versions of beta2-agonists were made by making some chemical changes in the short-acting beta2-agonists. These long-acting beta2-agonists are almost always prescribed together with anti-inflammatory medications for long-term control, rarely if ever by themselves. They are usually added when a conventional dose of an inhaled steroid is not adequate for control of daily symptoms.
There is evidence that rare patients experience loss of effect from their rapid-acting bronchodilator (eg, albuterol, levalbuterol) with taking long-acting bronchodilators. While this is quite uncommon, patients should be advised of this potential and instructed to notify their physician if the addition of a long-acting bronchodilator is associated with increased symptoms instead of the usual increased benefit.
Theophylline, usually taken by mouth as a timed-release pill, opens up the airways for an extended period. It can be used alone or together with inhaled corticosteroids. It can be particularly helpful in preventing nighttime symptoms in mild to moderate asthma. Although once used extensively, theophylline is currently infrequently prescribed for asthma, mainly because it requires careful monitoring of blood levels to avoid side effects and because other asthma medications often work as well or better.
Cromolyn Sodium and Nedocromil
These are very mildly effective anti-inflammatory medications rarely used anymore in long- term therapy of mild to moderate asthma in children.