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asthma exacerbations who are not taking inhaled corticosteroids should be started on an inhaled corticosteroid; symptomatic patients already taking an inhaled corticosteroid should have the dose increased Dosages for inhaled corticosteroids vary depending on the specific agent and delivery device The most important determinants of agent selection and appropriate dosing are the patient s status and response to treatment For most patients, twice-daily dosing provides adequate control of asthma Once-daily dosing may be sufficient in selected patients with mild persistent asthma Maximum responses from inhaled corticosteroids may not be observed for months The use of an inhalation chamber coupled with mouth washing after MDI use decreases local side effects (cough, dysphonia, oropharyngeal candidiasis) and systemic absorption DPIs are not used with an inhalation chamber Systemic effects (adrenal suppression, osteoporosis, skin thinning, easy bruising, and cataracts) may occur with high-dose inhalation therapy Systemic corticosteroids (oral or parenteral) are most effective in achieving prompt control of asthma during exacerbations or when initiating long-term asthma therapy In patients with severe persistent asthma, systemic corticosteroids are often required for the long-term suppression of symptoms Repeated efforts should be made to reduce the dose to the minimum needed to control symptoms Alternate-day treatment is preferred to daily treatment Rapid discontinuation of systemic corticosteroids after chronic use may precipitate adrenal insufficiency Concurrent treatment with calcium supplements and vitamin D should be initiated to prevent corticosteroid-induced bone mineral loss in longterm administration Bisphosphonates may offer additional protection to these patients 2 Long-acting bronchodilators a Mediator inhibitors Cromolyn sodium and nedocromil are long-term control medications that prevent asthma symptoms and improve airway function in patients with mild persistent asthma or exercise-induced asthma Both of these agents modulate mast cell mediator release and eosinophil recruitment and inhibit both early and late asthmatic responses to allergen challenge and exercise-induced bronchospasm They can be effective when taken before an exposure or exercise but do not relieve asthmatic symptoms once present The clinical response to these agents is less predictable than the response to inhaled corticosteroids Nedocromil may help reduce the dose requirements for inhaled corticosteroids Both agents have excellent safety profiles b -Adrenergic agents Long-acting 2-agonists provide bronchodilation for up to 12 hours after a single dose However, because their onset of action is delayed, they are not effective and should not be used in the treatment of acute bronchoconstriction Salmeterol and formoterol are the two agents in this class available in the United States They are administered via dry powder delivery devices They are indicated for long-term prevention of asthma symptoms, nocturnal symptoms, and for prevention of exercise-induced bronchospasm They should not be used in place of antiinflammatory therapy When added to standard doses of inhaled corticosteroids, salmeterol provides control equivalent to what is achieved by doubling the inhaled corticosteroid dose.

Anti-inflammatory agents, long-acting bronchodilators, and leukotriene modifiers comprise the important medications in this group of agents (Table 9 4) Other classes of agents are mentioned briefly below 1 Anti-inflammatory agents Corticosteroids are the most potent and consistently effective anti-inflammatory agents currently available They reduce both acute and chronic inflammation, resulting in fewer asthma symptoms, improvement in airflow, decreased airway hyperresponsiveness, fewer asthma exacerbations, and less airway remodeling These agents may also potentiate the action of -adrenergic agonists Inhaled corticosteroids are preferred for the long-term control of asthma and are first-line agents for patients with persistent asthma Patients with persistent symptoms or

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Long-Term Control Step 1: Mild intermittent No daily medication needed Short-acting bronchodilator: inhaled 2-agonists as needed for symptoms Intensity of treatment will depend on severity of exacerbation Use of short-acting inhaled 2-agonists > 2 times a week may indicate the need for long-term control therapy Teach basic facts about asthma Teach inhaler/inhalation chamber technique Discuss roles of medications Develop self-management and action plans Discuss appropriate environmental control measures Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update self-management plan Step 1 actions plus: Teach self-monitoring Refer to group education if available Review and update self-management plan Quick Relief Education

Step 2: Mild persistent One daily medication: Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil Less desirable alternatives: sustained-release theophylline or leukotriene modifier Step 3: Moderate persistent Daily medication: Either Anti-inflammatory: inhaled corticosteroid (medium dose) or Inhaled corticosteroid (low-medium dose) and a long-acting bronchodilator (long-acting inhaled 2-agonist, sustained-release theophylline or long-acting 2-agonist tablets) If needed: Anti-inflammatory: inhaled corticosteroid (medium-high dose) and Long-acting bronchodilator (long-acting inhaled 2-agonist, sustained-release theophylline or long-acting 2-agonist tablets) Daily medication: Anti-inflammatory: inhaled corticosteroid (high dose) and Long-acting bronchodilator (long-acting inhaled 2-agonist, sustained release theophylline or long-acting inhaled 2-agonist tablets) and Corticosteroid tablets or syrup (1 2 mg/kg/d, generally not to exceed 60 mg/d) As for step 2 Step 1 actions plus: Use of short-acting inhaled 2-agonists on a daily basis, or increasing use, indicates the need for additional long-term control therapy

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