Beyond the Wheeze: A Guide to Asthma Drugs

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1. Introduction: Understanding Asthma and Its Treatment

Asthma is a chronic respiratory disease characterized by inflammation of the airways, increased sensitivity to various triggers, and episodes of narrowing of the bronchial tubes. These changes can cause wheezing, coughing, chest tightness, and shortness of breath. Symptoms may vary from day to day and can become worse at night, during exercise, or after exposure to allergens, smoke, cold air, respiratory infections, and other irritants.

Asthma affects people of all ages. Some individuals experience occasional symptoms, while others develop frequent attacks that interfere with sleep, school, work, exercise, and daily activities. Severe asthma attacks can become life-threatening when airflow is critically reduced.

Fortunately, modern asthma medicines can control symptoms, reduce airway inflammation, improve lung function, and lower the risk of severe exacerbations. The main challenge is choosing the appropriate treatment for each patient and ensuring that the medicine is used correctly.

Asthma treatment is not based on opening the airways alone. It also requires controlling the inflammation responsible for airway swelling and preventing future attacks.

The major categories of asthma medicines include:

• Bronchodilators: Relax airway muscles and improve airflow.
• Inhaled corticosteroids: Reduce airway inflammation and prevent exacerbations.
• Combination inhalers: Deliver two or more medicines together.
• Leukotriene modifiers: Block inflammatory pathways involved in asthma.
• Long-acting antimuscarinic medicines: Provide additional bronchodilation in selected patients.
• Systemic corticosteroids: Treat significant exacerbations and selected severe cases.
• Biological medicines: Target specific immune pathways in severe asthma.
• Additional therapies: Include magnesium sulfate in selected severe attacks and other specialist treatments.

The Global Initiative for Asthma (GINA) emphasizes that asthma management should include an inhaled corticosteroid-containing treatment strategy rather than relying on a short-acting bronchodilator alone for routine care. Current recommendations should always be checked against the latest applicable guidelines.
Reference: https://ginasthma.org/2026-gina-strategy-report/

2. What Happens Inside the Airways During Asthma?

To understand how asthma drugs work, it is important to understand the changes occurring inside the respiratory system.

The airways consist of branching tubes that carry air from the trachea to the lungs. The smaller airways contain smooth muscle, a lining of epithelial cells, mucus-producing cells, and immune cells.

During asthma, several changes may occur.

2.1 Airway inflammation

Immune cells release inflammatory substances that cause swelling and irritation of the bronchial lining. Eosinophils, mast cells, T lymphocytes, and other cells may contribute to the inflammatory process.

Inflammation makes the airways more sensitive to triggers and increases the likelihood of an asthma attack.

Role of medication: Inhaled corticosteroids reduce airway inflammation and are central to long-term asthma control.

2.2 Bronchoconstriction

The smooth muscles surrounding the airways contract, narrowing the passage through which air flows.

This narrowing increases resistance to airflow and can produce wheezing, chest tightness, and difficulty breathing.

Role of medication: Beta-2 agonists and antimuscarinic medicines relax airway smooth muscle and help widen the airways.

2.3 Excess mucus production

Inflamed airways may produce more mucus than usual. Thick mucus can further obstruct airflow, particularly during severe exacerbations.

Role of medication: Controlling inflammation can reduce mucus-related airway changes over time. Bronchodilators help relieve associated narrowing, but they do not directly remove every mucus plug.

2.4 Airway hyperresponsiveness

People with asthma may respond excessively to stimuli such as dust mites, pollen, smoke, cold air, strong odors, exercise, or viral infections.

A trigger that causes little difficulty in another person may provoke substantial bronchoconstriction in someone with asthma.

Role of medication: Anti-inflammatory treatment reduces airway sensitivity over time, while reliever medicines help relieve acute symptoms.

2.5 Airway remodeling

In some patients, long-standing poorly controlled inflammation contributes to structural changes, including thickening of the airway wall and increased smooth muscle mass. These changes may make airflow limitation less reversible.

Early diagnosis, appropriate treatment, and regular follow-up help reduce the risk of ongoing uncontrolled disease.

3. Classification of Drugs Used in Asthma

Asthma medicines are commonly classified according to their primary role.

A. Reliever medicines

Relievers provide rapid or relatively rapid relief of symptoms by opening the airways or combining bronchodilation with anti-inflammatory treatment.

Examples include:

• Short-acting beta-2 agonists, such as salbutamol.
• Low-dose inhaled corticosteroid-formoterol combinations, when prescribed as an anti-inflammatory reliever.
• Ipratropium bromide, mainly as an additional medicine in selected acute attacks.

The appropriate reliever depends on the patient's prescribed treatment plan.

B. Controller medicines

Controller medicines reduce inflammation, prevent symptoms, and lower the risk of future attacks.

Examples include:

• Inhaled corticosteroids.
• Inhaled corticosteroid-long-acting beta-2 agonist combinations.
• Leukotriene receptor antagonists.
• Long-acting muscarinic antagonists in selected patients.
• Biological therapies for eligible patients with severe asthma.

C. Medicines for acute exacerbations

Moderate or severe asthma exacerbations may require:

• Repeated inhaled or nebulized bronchodilators.
• Systemic corticosteroids.
• Ipratropium bromide in selected severe attacks.
• Controlled oxygen when hypoxemia is present.
• Intravenous magnesium sulfate in selected patients with severe symptoms that respond inadequately to initial treatment.

These medicines are administered according to the severity of the attack and the patient's clinical condition.

4. Short-Acting Beta-2 Agonists (SABAs)

Short-acting beta-2 agonists are bronchodilators that relax the smooth muscles surrounding the airways.

They have traditionally been widely used for rapid relief of asthma symptoms. However, current asthma strategies generally avoid SABA-only treatment because it does not adequately address airway inflammation.

4.1 Salbutamol

Salbutamol, also known as albuterol in some countries, is one of the most familiar bronchodilators used in asthma care.

Common routes: Metered-dose inhaler, dry powder inhaler where available, and nebulization. The route and dose depend on the clinical situation and prescribed product.

Mechanism of action

Salbutamol stimulates beta-2 adrenergic receptors on bronchial smooth muscle. This activates intracellular signaling that reduces smooth muscle contraction.

The airways widen, airflow improves, and symptoms such as wheezing and chest tightness may decrease.

Clinical uses

• Relief of acute bronchoconstriction.
• Symptom relief during an asthma exacerbation.
• Prevention of exercise-induced bronchoconstriction when specifically prescribed.
• Additional bronchodilation during acute treatment in healthcare settings.

Adverse effects

Common adverse effects include:

• Tremor or shakiness.
• Palpitations.
• Increased heart rate.
• Headache.
• Nervousness.

Repeated high doses can contribute to low blood potassium and elevated blood lactate. Significant adverse effects require clinical assessment.

Important precautions

Increasing reliance on salbutamol may indicate that asthma is poorly controlled. Frequent need for a reliever should prompt a review of anti-inflammatory treatment, inhaler technique, adherence, and possible triggers.

Salbutamol provides bronchodilation, but it does not replace inhaled corticosteroids.

4.2 Terbutaline

Terbutaline is another beta-2 agonist that can relax bronchial smooth muscle.

Depending on the country and product, it may be available in inhaled or systemic formulations. Inhaled preparations can provide bronchodilation, while systemic administration carries greater potential for adverse effects.

Potential adverse effects include tremor, palpitations, tachycardia, and electrolyte disturbances.

Its exact place in treatment depends on the available formulation and local clinical guidance.

4.3 Levalbuterol

Levalbuterol is the R-enantiomer of albuterol. It is available in some countries and may be used as a bronchodilator.

It acts on beta-2 receptors, producing relaxation of bronchial smooth muscle. Its availability and comparative clinical advantages vary, and it should not automatically be assumed to eliminate cardiovascular or tremor-related adverse effects.

Key point about SABAs

Short-acting beta-2 agonists relieve bronchoconstriction but do not adequately treat the underlying inflammation when used alone. A patient with asthma should have an appropriate inhaled corticosteroid-containing treatment plan.

Reference: https://www.nhlbi.nih.gov/health/asthma/treatment-action-plan

5. Long-Acting Beta-2 Agonists (LABAs)

Long-acting beta-2 agonists produce prolonged bronchodilation. They are useful for maintaining open airways over an extended period.

Common examples include:

• Formoterol.
• Salmeterol.
• Vilanterol.
• Indacaterol, which has a role in selected respiratory treatment regimens and is not a routine stand-alone asthma treatment.

Not every LABA is licensed for every age group, and different products have different dosing schedules.

5.1 Formoterol

Formoterol is a long-acting bronchodilator with a relatively rapid onset of action.

This rapid onset is especially important because certain inhalers containing formoterol and an inhaled corticosteroid can be prescribed both for regular maintenance and for symptom relief. This approach is known as maintenance-and-reliever therapy, or MART.

Mechanism of action

Formoterol stimulates beta-2 receptors and activates signaling pathways that relax bronchial smooth muscle.

Uses

• Long-term asthma control when combined with an inhaled corticosteroid.
• Maintenance-and-reliever therapy with an appropriate inhaled corticosteroid-formoterol product.
• Improvement of symptoms and reduction of exacerbation risk in suitable patients.

Adverse effects

• Tremor.
• Palpitations.
• Headache.
• Muscle cramps.
• Low potassium, particularly with excessive beta-2 agonist exposure.

Important distinction

Formoterol used alone is not an appropriate substitute for anti-inflammatory asthma treatment. When used for asthma, it should be part of an appropriate corticosteroid-containing regimen.

5.2 Salmeterol

Salmeterol is a long-acting beta-2 agonist with a slower onset than formoterol.

It is used for maintenance treatment in combination with an inhaled corticosteroid.

Salmeterol is not intended for rapid relief of an acute asthma attack. Inhalers containing salmeterol should not be used as the reliever in a maintenance-and-reliever regimen designed for formoterol.

5.3 Vilanterol

Vilanterol is a long-acting beta-2 agonist included in certain combination inhalers.

It is used with an appropriate inhaled corticosteroid in asthma treatment where the product is approved.

Patients should follow the specific product's prescribed schedule rather than using it as an extra dose for sudden symptoms unless their clinician has explicitly instructed otherwise.

Why must LABAs be combined with inhaled corticosteroids in asthma?

LABAs improve airflow but do not adequately control the underlying inflammation when used alone. LABA monotherapy in asthma is associated with an increased risk of serious asthma-related outcomes.

Therefore, LABAs used for asthma should be prescribed in combination with inhaled corticosteroid treatment.

6. Inhaled Corticosteroids (ICS): The Foundation of Asthma Control

Inhaled corticosteroids are among the most important drugs used for long-term asthma management.

Unlike bronchodilators, which mainly relax airway muscles, inhaled corticosteroids target inflammation.

Common examples include:

• Budesonide.
• Beclometasone dipropionate.
• Fluticasone propionate.
• Fluticasone furoate.
• Mometasone furoate.
• Ciclesonide.

Different preparations vary in potency, particle characteristics, device requirements, approved age groups, and dosing. Their microgram doses should not be assumed to be interchangeable.

6.1 Mechanism of action

Corticosteroids enter airway cells and bind to intracellular glucocorticoid receptors. The resulting changes in gene expression reduce inflammatory signaling.

They help reduce:

• Inflammatory cell activity.
• Production of inflammatory mediators.
• Airway swelling.
• Mucus-related inflammatory changes.
• Airway hyperresponsiveness.
• The frequency and severity of exacerbations.

Their full preventive benefit develops through regular use rather than immediate relaxation of the bronchial muscles.

6.2 Budesonide

Budesonide is a widely used inhaled corticosteroid available in several inhaled formulations. It is also included in combination inhalers with formoterol.

Clinical uses:

• Maintenance treatment of asthma.
• Reduction of asthma exacerbation risk.
• Use in prescribed inhaled corticosteroid-formoterol regimens.
• Selected nebulized treatment regimens in particular age groups and clinical circumstances.

Budesonide should be used according to the prescribed dose and device instructions.

6.3 Beclometasone dipropionate

Beclometasone is an inhaled corticosteroid used to control persistent asthma.

It reduces airway inflammation and helps prevent symptoms over time.

The dose depends on the specific inhaler formulation. Different devices and formulations may deliver different amounts of medicine to the lungs.

6.4 Fluticasone

Fluticasone is another inhaled corticosteroid used for asthma control.

It is available in different formulations and in combination with long-acting bronchodilators.

Its main role is prevention of airway inflammation and exacerbations, not immediate relief of bronchoconstriction.

6.5 Mometasone

Mometasone is an inhaled corticosteroid used in certain asthma maintenance products.

It suppresses airway inflammation and may be combined with a long-acting beta-2 agonist in approved products.

6.6 Ciclesonide

Ciclesonide is an inhaled corticosteroid that is converted into an active metabolite in the lungs.

It is used for maintenance treatment in suitable patients. As with other inhaled corticosteroids, correct technique and regular adherence are important.

Adverse effects of inhaled corticosteroids

Common local effects include:

• Oral candidiasis, also called oral thrush.
• Hoarseness or dysphonia.
• Throat irritation.
• Cough immediately after inhalation in some patients.

At higher doses or with prolonged exposure, systemic effects can occur, including adrenal suppression, effects on bone health, skin bruising, cataract or glaucoma risk, and effects on growth in children.

The risk depends on the dose, duration, formulation, patient characteristics, and use of other corticosteroid medicines.

How to reduce adverse effects

• Use the lowest dose that maintains adequate asthma control.
• Rinse the mouth and spit out the water after using an inhaled corticosteroid.
• Use a spacer with a compatible pressurized metered-dose inhaler when appropriate.
• Review inhaler technique regularly.
• Attend follow-up appointments to assess control and adverse effects.

Inhaled corticosteroids are highly valuable medicines. Concerns about side effects should lead to a discussion about dose, technique, and monitoring rather than stopping treatment without medical advice.

Reference: https://www.nhs.uk/medicines/beclometasone-inhalers/side-effects-of-beclometasone-inhalers/

7. Combination Inhalers: Treating Inflammation and Bronchoconstriction Together

Combination inhalers contain two medicines in a single device. The most important asthma combinations include an inhaled corticosteroid and a long-acting beta-2 agonist.

They combine the anti-inflammatory action of a corticosteroid with the bronchodilator effect of a LABA.

Examples include:

• Budesonide-formoterol.
• Beclometasone-formoterol.
• Fluticasone-salmeterol.
• Fluticasone furoate-vilanterol.
• Mometasone-formoterol.

Availability and licensing differ by country.

7.1 Budesonide-formoterol

This combination is especially important because some approved products can be used for both maintenance and symptom relief.

Budesonide reduces inflammation, while formoterol relaxes bronchial smooth muscle.

Depending on the prescribed regimen, the inhaler may be used:

• Regularly for maintenance.
• As needed for symptom relief.
• For both purposes under a maintenance-and-reliever therapy plan.

The exact product, age group, strength, and prescribed maximum daily use must be checked carefully.

7.2 Beclometasone-formoterol

This combination delivers an inhaled corticosteroid and a rapid-onset LABA.

In appropriate approved regimens, it may be used for maintenance and reliever therapy. Patients must follow the instructions for their exact product because not every combination inhaler is suitable for this purpose.

7.3 Fluticasone-salmeterol

This combination is generally used as regular maintenance treatment.

Fluticasone controls inflammation, while salmeterol provides prolonged bronchodilation.

Because salmeterol does not have the same rapid-onset role as formoterol, this combination should not be used as an as-needed reliever in a MART regimen.

7.4 Fluticasone furoate-vilanterol

This combination provides maintenance anti-inflammatory and bronchodilator treatment in a once-daily regimen for appropriate patients where approved.

It is not intended for immediate relief of a sudden asthma attack.

Maintenance-and-reliever therapy (MART)

MART uses a suitable inhaled corticosteroid-formoterol inhaler for both scheduled maintenance treatment and additional symptom relief.

Potential advantages include:

• One inhaler for two purposes.
• Increased delivery of anti-inflammatory medicine when symptoms worsen.
• Reduced risk of severe exacerbations in suitable patients.
• A simplified treatment plan for some individuals.

MART must be prescribed with a product and regimen supported by the relevant guidelines. A patient should not independently convert an existing combination inhaler into a reliever.

GINA describes the benefits of ICS-formoterol maintenance-and-reliever treatment for suitable patients.
Reference: https://ginasthma.org/2026-gina-strategy-report/

8. Leukotriene Modifiers

Leukotrienes are inflammatory mediators involved in bronchoconstriction, airway swelling, mucus production, and increased airway responsiveness.

Leukotriene modifiers interfere with this pathway.

The most familiar example is montelukast.

8.1 Montelukast

Montelukast is a leukotriene receptor antagonist. It blocks cysteinyl leukotriene type 1 receptors, reducing some of the effects of leukotrienes in the respiratory tract.

Uses

• Additional control in selected patients with persistent asthma.
• Selected cases of exercise-induced bronchoconstriction.
• Asthma associated with allergic rhinitis in appropriate patients.
• Situations where an oral option is useful and clinically appropriate.

Montelukast is not a substitute for inhaled corticosteroids in patients who require ICS-containing treatment.

Adverse effects

Possible adverse effects include:

• Headache.
• Abdominal discomfort.
• Gastrointestinal symptoms.
• Sleep disturbances.
• Behavioral or mood changes.

Montelukast carries an important warning concerning serious neuropsychiatric effects, including mood and behavioral changes and suicidal thoughts or actions. Patients and caregivers should discuss these risks with a healthcare professional and seek prompt medical advice if concerning changes occur.

8.2 Zafirlukast

Zafirlukast is another leukotriene receptor antagonist used in some countries.

It may be prescribed for maintenance treatment in selected patients. It has important administration considerations, potential drug interactions, and a risk of liver injury.

It is not intended to provide immediate relief during an acute asthma attack.

8.3 Zileuton

Zileuton inhibits 5-lipoxygenase, an enzyme involved in leukotriene synthesis.

It is available in some countries for selected asthma patients. Because of potential liver toxicity and drug interactions, it requires appropriate monitoring and is not a routine first-line choice for most patients.

Limitations of leukotriene modifiers

Although oral administration can be convenient, these medicines are generally less effective than inhaled corticosteroids for preventing exacerbations in many patients with persistent asthma.

They may be useful as add-on therapy, but treatment selection should be individualized.

9. Long-Acting Muscarinic Antagonists (LAMAs)

Muscarinic receptors contribute to bronchial smooth muscle contraction through cholinergic signaling.

Antimuscarinic medicines block these receptors and help relax the airways.

9.1 Tiotropium

Tiotropium is a long-acting muscarinic antagonist used as an additional maintenance medicine in selected patients whose asthma remains inadequately controlled despite appropriate inhaled treatment.

Mechanism of action

Tiotropium blocks muscarinic receptors in airway smooth muscle, reducing cholinergic bronchoconstriction.

Uses

• Add-on maintenance treatment for selected patients with persistent asthma.
• Additional bronchodilation when standard inhaled treatment is insufficient.

Tiotropium is not intended to replace inhaled corticosteroids and is not a first-choice rescue medicine for a sudden attack.

Adverse effects

• Dry mouth.
• Throat irritation.
• Constipation in some patients.
• Urinary retention in susceptible individuals.
• Eye symptoms if the aerosol enters the eyes.

Caution may be needed in patients with certain urinary or eye conditions.

9.2 Other LAMAs

Other long-acting muscarinic antagonists are available in respiratory medicine, and some products combine a LAMA with other bronchodilators. Their role in asthma depends on product approval and the applicable treatment guidelines.

Not all medicines commonly used for chronic obstructive pulmonary disease (COPD) are appropriate or approved for asthma.

10. Short-Acting Antimuscarinic Medicines

Ipratropium bromide

Ipratropium is a short-acting antimuscarinic bronchodilator.

It blocks muscarinic receptors and reduces cholinergic bronchoconstriction.

In acute asthma management, ipratropium may be added to a short-acting beta-2 agonist in selected moderate-to-severe exacerbations, especially in emergency or hospital settings.

It is generally not as effective as a beta-2 agonist when used alone for rapid asthma relief.

Potential adverse effects include dry mouth, throat irritation, and blurred vision if the medicine reaches the eyes.

11. Systemic Corticosteroids

Systemic corticosteroids are medicines that produce anti-inflammatory effects throughout the body.

They are especially important in significant asthma exacerbations, where airway inflammation can worsen rapidly.

Common examples include:

• Prednisolone or prednisone.
• Hydrocortisone.
• Methylprednisolone.
• Dexamethasone in selected protocols.

The choice depends on the patient's age, clinical severity, ability to take oral medication, and local protocols.

11.1 Prednisolone

Prednisolone is commonly used orally for short courses during significant exacerbations.

It reduces inflammation and helps lower the risk of deterioration or relapse after an acute attack.

It does not act as an immediate bronchodilator. It is usually given alongside inhaled bronchodilator treatment when indicated.

11.2 Hydrocortisone

Intravenous hydrocortisone may be used in selected hospitalized patients, particularly when oral medication cannot be taken or when a hospital protocol supports parenteral therapy.

11.3 Methylprednisolone

Methylprednisolone may be administered orally or intravenously, depending on the clinical situation and formulation.

When are systemic corticosteroids used?

They may be needed when:

• Symptoms are severe or rapidly worsening.
• Initial reliever treatment does not provide adequate improvement.
• The patient has a significant exacerbation requiring emergency care.
• A clinician determines that the risk of relapse or continued deterioration warrants treatment.

Not every episode of mild wheezing requires oral or intravenous steroids.

Adverse effects

Short courses may cause:

• Increased appetite.
• Indigestion.
• Sleep disturbance.
• Mood changes.
• Temporary increases in blood glucose.
• Fluid retention in some patients.

Repeated courses or long-term systemic use increase the risk of osteoporosis, hypertension, diabetes, infection, cataracts, adrenal suppression, and other complications.

The goal is to control asthma with an appropriate inhaled regimen and minimize repeated systemic corticosteroid exposure.

12. Theophylline and Aminophylline

Theophylline is a methylxanthine bronchodilator. Aminophylline is a compound that releases theophylline in the body.

These medicines have historically been used for asthma, but their role has declined because safer and more effective alternatives are available.

Mechanism of action

Theophylline has several pharmacological effects, including inhibition of phosphodiesterase enzymes and antagonism of adenosine receptors at relevant concentrations. These actions can contribute to bronchodilation and other systemic effects.

Limitations

Theophylline has a narrow therapeutic index, meaning that the difference between an effective concentration and a toxic concentration can be small.

Potential adverse effects include:

• Nausea and vomiting.
• Tremor.
• Insomnia.
• Palpitations.
• Abnormal heart rhythms.
• Seizures in severe toxicity.

Its concentration may be affected by drug interactions, smoking status, illness, and changes in liver function.

Intravenous aminophylline is generally not recommended for routine treatment of acute asthma exacerbations because its additional benefit is limited and toxicity can be significant.

If a specialist prescribes a methylxanthine, careful monitoring and review of interacting medicines are essential.

13. Magnesium Sulfate in Severe Asthma

Magnesium sulfate is not a routine daily controller medicine. It may be used in selected severe asthma exacerbations when initial treatment has not produced sufficient improvement.

Mechanism of action

Magnesium may help relax bronchial smooth muscle by influencing calcium-dependent processes and other cellular mechanisms.

Route and clinical role

In emergency care, intravenous magnesium sulfate may be considered for selected patients with severe exacerbations that respond inadequately to initial bronchodilator and corticosteroid treatment.

Nebulized magnesium is not a routine standard treatment for asthma exacerbations.

Adverse effects and precautions

Intravenous administration can cause:

• Flushing.
• Nausea.
• Low blood pressure.
• Muscle weakness.
• Cardiac or respiratory complications in severe toxicity.

The dose, infusion rate, and monitoring must follow an appropriate emergency protocol.

14. Biological Medicines for Severe Asthma

Some patients continue to experience severe exacerbations despite optimized inhaled treatment, correct inhaler technique, good adherence, and management of relevant contributing conditions.

In selected cases, specialists may prescribe biological medicines that target specific immune pathways.

These treatments are not suitable for every person with asthma. Selection often depends on clinical history, exacerbation frequency, blood eosinophil counts, immunoglobulin E levels, allergic sensitization, and other biomarkers.

14.1 Omalizumab

Omalizumab is an anti-IgE monoclonal antibody.

Immunoglobulin E (IgE) plays an important role in many allergic responses. Omalizumab binds to free IgE and reduces its availability to activate certain immune cells.

It may be used for selected patients with allergic asthma that remains uncontrolled despite appropriate standard treatment.

Potential adverse effects include injection-site reactions and headache. Rarely, serious allergic reactions can occur, so administration and observation should follow the relevant product guidance.

14.2 Mepolizumab

Mepolizumab targets interleukin-5 (IL-5), a cytokine involved in eosinophil production and survival.

It may benefit eligible patients with severe eosinophilic asthma by reducing exacerbations and the need for systemic corticosteroids in selected circumstances.

14.3 Reslizumab

Reslizumab is another treatment targeting IL-5.

It is used in selected patients with severe eosinophilic asthma according to its approved indications. It is administered under medical supervision because serious infusion-related reactions can occur.

14.4 Benralizumab

Benralizumab targets the IL-5 receptor alpha chain on eosinophils and promotes their depletion.

It may be appropriate for certain patients with severe eosinophilic asthma.

14.5 Dupilumab

Dupilumab blocks signaling through the interleukin-4 receptor alpha pathway, affecting IL-4 and IL-13 signaling.

It may be used for eligible patients with certain forms of severe asthma, particularly those with relevant type 2 inflammation or other approved indications.

14.6 Tezepelumab

Tezepelumab targets thymic stromal lymphopoietin (TSLP), an epithelial-cell-derived cytokine involved in initiating and amplifying several inflammatory pathways.

It may be used for eligible patients with severe asthma according to the approved indication and local guidelines.

Benefits and limitations of biological therapies

Biological medicines may reduce exacerbations, improve asthma control, and lower dependence on oral corticosteroids in selected patients.

However:

• They are usually expensive.
• They require specialist assessment.
• Eligibility criteria vary.
• They do not immediately reverse an acute asthma attack.
• They do not automatically eliminate the need for inhaled treatment.
• Patients require follow-up to assess effectiveness and adverse effects.

Biological therapy is generally considered after the diagnosis, adherence, inhaler technique, comorbidities, and standard treatment have been carefully reviewed.

15. Cromones and Other Less-Common Medicines

15.1 Sodium cromoglicate

Sodium cromoglicate, also known as cromolyn in some countries, is a mast-cell stabilizing medicine.

It can reduce the release of inflammatory mediators from mast cells under certain conditions.

Its role in asthma is limited compared with inhaled corticosteroids, and availability varies by country.

It is not a rapid bronchodilator and is not appropriate as the sole treatment for a severe acute attack.

15.2 Nedocromil

Nedocromil is another cromone medicine that has been used for asthma prevention in some settings.

It is not widely available in many markets and is now used much less frequently than inhaled corticosteroid-based treatment.

15.3 Antihistamines

Antihistamines such as cetirizine or loratadine may help treat associated allergic rhinitis or urticaria in appropriate patients.

However, they are not primary medicines for controlling asthma itself. Treating nasal allergy may improve overall comfort and help manage coexisting allergic disease, but antihistamines do not replace inhaled asthma treatment.

16. Drugs That May Worsen Asthma in Susceptible Patients

Some medicines can trigger bronchospasm or worsen asthma in particular individuals.

16.1 Non-selective beta blockers

Medicines such as propranolol can block beta-2 receptors and provoke bronchoconstriction.

Even some ophthalmic beta-blocker preparations can have systemic effects.

Beta blockers may be necessary for important cardiovascular conditions, so a patient should not discontinue them independently. A clinician must assess the risks, benefits, and possible alternatives.

16.2 Aspirin and non-steroidal anti-inflammatory drugs

Aspirin and other NSAIDs can provoke respiratory symptoms in susceptible patients, particularly those with aspirin-exacerbated respiratory disease.

This does not mean every patient with asthma must avoid every NSAID. The history of reactions and individual risk should guide treatment decisions.

16.3 Other medicines and exposures

Some patients may experience worsening symptoms with particular drugs, occupational exposures, smoke, or strong chemical irritants.

A medication review is especially important when asthma control deteriorates after a new treatment is started.

17. Stepwise Pharmacological Management of Asthma

Asthma treatment is adjusted according to symptom control, exacerbation risk, lung function, age, and treatment response.

The aim is to achieve good control with the lowest effective treatment burden while preventing severe attacks.

Step 1: Assess the patient

Before increasing treatment, the clinician should assess:

• Frequency of daytime symptoms.
• Night-time waking.
• Limitation of daily activities.
• Use of reliever medicines.
• Previous severe exacerbations.
• Lung function where appropriate.
• Inhaler technique and adherence.
• Smoking, allergens, and other relevant exposures.
• Coexisting conditions such as allergic rhinitis or obesity.

Poor control does not always mean that the patient needs a stronger medicine. Incorrect technique, missed doses, ongoing triggers, and an incorrect diagnosis can all contribute.

Step 2: Choose an appropriate ICS-containing regimen

Current GINA recommendations favor an inhaled corticosteroid-containing approach for adolescents and adults, with the specific regimen determined by the patient's clinical situation and available products.

Depending on the patient and local guidelines, options may include:

• An anti-inflammatory reliever containing low-dose ICS-formoterol.
• Regular maintenance ICS-formoterol with additional use of the same inhaler as prescribed.
• Regular inhaled corticosteroid treatment with an appropriate separate reliever.
• An ICS-LABA maintenance inhaler with an appropriate reliever.

SABA-only treatment is not the preferred long-term strategy for routine asthma management under current GINA guidance.

Step 3: Adjust treatment when control remains inadequate

If asthma remains poorly controlled, the clinician should first confirm:

• The diagnosis is correct.
• The patient is using the inhaler properly.
• Prescribed medicines are being taken consistently.
• Relevant triggers and comorbidities are addressed.

If these factors have been reviewed, the treatment may be adjusted, for example by optimizing the ICS-containing regimen or adding a suitable long-acting bronchodilator.

Step 4: Consider additional therapy

For selected patients, additional options may include:

• A leukotriene receptor antagonist.
• A LAMA such as tiotropium.
• Specialist assessment for severe asthma.
• A suitable biological medicine.

Step 5: Review and step down when appropriate

Once asthma has been well controlled for a sustained period, a clinician may consider carefully reducing treatment to the lowest effective level.

Inhaled corticosteroids should not be stopped abruptly or reduced without an appropriate plan, because symptoms and exacerbation risk may return.

Children require age-specific assessment and treatment selection.

Reference: https://ginasthma.org/2026-gina-strategy-report/

18. Emergency Treatment of an Acute Asthma Attack

An acute exacerbation occurs when asthma symptoms worsen beyond the patient's usual variation. The attack may develop over minutes, hours, or days.

Severe attacks can cause respiratory failure and require urgent medical attention.

18.1 Initial assessment

Healthcare professionals assess:

• Ability to speak in full sentences.
• Respiratory rate and work of breathing.
• Heart rate.
• Oxygen saturation.
• Mental status.
• Air entry and wheezing.
• Peak expiratory flow when feasible.
• Response to initial treatment.

A patient who is exhausted, confused, cyanosed, unable to speak, or showing markedly reduced air entry needs emergency assessment.

18.2 Inhaled bronchodilators

A short-acting beta-2 agonist such as salbutamol is commonly used during acute treatment.

It may be administered through a suitable inhaler with a spacer or through nebulization, depending on severity and the clinical setting.

Repeated doses may be required under medical supervision.

18.3 Ipratropium bromide

Ipratropium may be added to a short-acting beta-2 agonist in selected severe attacks.

The combination can improve bronchodilation in appropriate patients.

18.4 Systemic corticosteroids

Oral prednisolone or another suitable systemic corticosteroid may be given for a significant exacerbation.

Intravenous corticosteroids may be used when oral administration is not possible or when the clinical circumstances require it.

These medicines reduce inflammation but do not replace immediate bronchodilator treatment.

18.5 Oxygen

Supplemental oxygen is used when needed to correct hypoxemia. It should be titrated according to oxygen saturation and the applicable emergency protocol.

Oxygen is a supportive treatment; it does not itself reverse bronchospasm.

18.6 Intravenous magnesium sulfate

Magnesium sulfate may be considered in selected severe exacerbations that respond inadequately to initial treatment.

It is not required for every asthma attack.

18.7 Escalation of care

Patients who fail to improve or show signs of impending respiratory failure require urgent senior review and escalation of care. Intensive care support may be necessary in life-threatening cases.

Sedatives should not be routinely used to treat an asthma attack because they can worsen respiratory compromise.

Emergency warning: Severe breathlessness, inability to speak normally, blue or grey lips, confusion, exhaustion, or poor response to prescribed reliever treatment are reasons to seek emergency care immediately. Do not delay urgent care while trying additional medicines at home.

19. Asthma Medicines in Children

Asthma management in children requires special attention to age, diagnosis, inhaler technique, growth, caregiver education, and the risk of exacerbations.

19.1 Inhaled corticosteroids

Inhaled corticosteroids are important controller medicines for many children with persistent asthma.

The dose and device should be appropriate for the child's age and ability. A spacer and, for younger children, a suitable face mask may improve delivery when used with compatible devices.

19.2 Salbutamol

Salbutamol may be used for symptom relief according to the child's prescribed action plan.

A spacer can be particularly useful for children who cannot coordinate inhaler actuation with inhalation.

19.3 Combination inhalers

Some children may benefit from combination inhalers or maintenance-and-reliever strategies, depending on their age, asthma severity, the approved product, and local guidelines.

Adult treatment instructions should not simply be copied for a young child.

19.4 Monitoring growth

Long-term inhaled corticosteroid treatment may have a small effect on growth velocity in some children, particularly at higher doses. Poorly controlled asthma and repeated systemic steroid courses also carry risks.

Clinicians should monitor growth, use the lowest effective dose, and balance potential risks against the benefits of preventing asthma attacks.

19.5 Caregiver education

Parents and caregivers should understand:

• Which inhaler is used regularly.
• Which medicine is used for symptom relief.
• How to use the device and spacer.
• When to seek urgent medical care.
• How to follow the written asthma action plan.

20. Asthma Treatment During Pregnancy

Good asthma control during pregnancy is important for both the pregnant patient and the developing baby.

Poorly controlled asthma and severe exacerbations can cause maternal and fetal complications, including problems associated with inadequate oxygenation.

Important principles

• Continue prescribed controller treatment unless the treating clinician advises otherwise.
• Inhaled corticosteroids are important for maintaining asthma control.
• Do not stop an inhaler simply because pregnancy has occurred.
• Seek early medical review if symptoms worsen or reliever use increases.
• Treat significant exacerbations promptly.

The choice of medicine should be reviewed by the clinician familiar with the pregnancy and the patient's asthma history. The risks of uncontrolled asthma must be considered alongside medication risks.

Conclusion: The Right Medicine Must Target the Right Problem

Asthma treatment is most effective when it addresses both the narrowing of the airways and the inflammation that makes them sensitive to triggers.

Bronchodilators such as salbutamol and formoterol help relax bronchial smooth muscle. Inhaled corticosteroids such as budesonide, beclometasone, and fluticasone reduce airway inflammation. Combination inhalers bring these effects together, while leukotriene modifiers and long-acting muscarinic antagonists can provide additional benefits in selected patients.

Systemic corticosteroids and other emergency treatments are important when an exacerbation becomes significant. Biological medicines offer targeted options for some patients with severe asthma whose disease remains uncontrolled despite optimized standard treatment.

However, choosing a drug is only one part of successful management. Correct diagnosis, appropriate inhaler technique, adherence, regular review, trigger management, and a clear written action plan are equally important.

The central principle is straightforward: effective asthma care should relieve symptoms, control inflammation, prevent severe attacks, and use the safest effective treatment for each individual.

Medical Disclaimer

This article is intended for educational purposes for medical, pharmacy, nursing, and other healthcare learners, as well as readers seeking general information. It does not replace professional diagnosis, current clinical guidelines, or individualized medical advice. Medicine selection, dose, route, duration, and monitoring depend on age, clinical severity, medical history, product availability, and local protocols. Severe breathing difficulty or a poorly responding asthma attack requires urgent medical attention.