Long-term management of asthma – Related resources

Cochrane reviews

Drug therapy

Inhaled corticosteroids

• Inhaled corticosteroids appear to be as effective as a daily dose of 7.5 to 10 mg or prednisolone, probably with fewer adverse effects .Inhaled beclomethasone appears to have a small dose-response effect, but the clinical significance of this effect is not clear .Inhaled fluticasone given at half the daily dose of beclomethasone or budesonide leads to small improvements in measures of airway calibre, but at the same daily dose it appears to have a higher risk of causing hoarseness and adrenal suppression .
• In the treatment of asthma, commencing with a moderate dose of inhaled corticosteroids (ICS) provides equivalent clinical benefits as commencing with a high dose ICS and down-titrating .
• In moderate to severe asthma, combined budesonide/formoterol inhaler for relief of asthma symptoms appears to reduce exacerbations but not hospital admissions compared with a beta2-agonist alone. In mild asthma, the combination may not provide any clinically important benefits compared with formoterol alone .
• Combination of long-acting beta-2 agonists with inhaled corticosteroids modestly reduces the risk of exacerbations requiring oral corticosteroids, improves lung function and symptoms in adult asthmatics as compared with increasing the dose of inhaled corticosteroids.Combinations fluticasone/salmeterol and budesonide/formoterol administered at fixed dose with a single inhaler appear to have similar clinical effectiveness in the treatment of chronic asthma, and they seem not to have differences in serious adverse events. .The initiation of inhaled corticosteroids in combination with long-acting beta2-agonists does not significantly reduce the rate of exacerbations over that achieved with inhaled corticosteroids alone .
• Single inhaler therapy combining formoterol and budesonide appears to reduce the risk of asthma exacerbations needing oral corticosteroids in comparison with fixed dose maintenance inhaled corticosteroids, but has not been demonstrated to significantly reduce exacerbations in comparison with current best practice .
• Intermittent inhaled corticosteroids appear to have a similar effect on acute exacerbations of asthma as daily inhaled corticosteroids, although they appear to be associated with slightly inferior lung function, airway inflammation and asthma control .

Beta2-agonists

• Beta₂-agonists, both short-acting (SABA) and long-acting (LABA), when administered in a single dose, may be effective in preventing exercise-induced asthma. Longer-term administration of inhaled beta₂-agonists appears to induce tolerance and lack sufficient safety data .
• Long-acting beta₂-agonists (LABA) appear to be associated with more serious adverse events than placebo in adults with asthma. Combination of corticosteroids to LABA appears to reduce adverse events .Long acting inhaled beta-agonists have better physiological and clinical outcomes than short acting beta-agonists in regular treatment of asthma but their long-term safety raises concerns .Regular inhaled long-acting beta2-agonists appear to entail an increased risk of serious adverse events in the treatment of chronic asthma .For adults using moderate to high maintenance doses of inhaled corticosteroid (ICS) for asthma, the addition of a long acting beta agonist has an ICS-sparing effect .Long acting beta agonists (salmeterol or formoterol), with or without inhaled corticosteroids (ICS), are more effective than placebo for a variety of outcomes for stable chronic asthma. However, potential safety issues raise concerns particularly in those asthmatics not taking ICS .Salmeterol improves morning and evening PEF values as compared to theophylline in the maintenance treatment of adult asthma but the effect on FEV1 is not significantly different. Adverse events and need for rescue medication are less common with salmeterol .

Other drugs

Methotrexate may have a small steroid sparing effect in adults with asthma who are dependent on oral corticosteroids. However, the overall reduction in daily steroid use is probably not large enough to reduce steroid-induced adverse effects .Use of cyclosporin may reduce the need of oral steroids in asthma but side effects are common .Gold may reduce the need of steroids in asthma, but given the side effects and necessity for monitoring the treatment cannot be recommended .
• There is no evidence to support the use of azathioprine in the treatment of chronic asthma as a steroid sparing-agent .Nedochromil sodium and cromoglycate appear to be as effective in preventing exercise-induced bronchoconstriction .Mast-cell stabilizers are more effective than anticholinergics but less effective than beta-agonists in the prevention of exercise-induced bronchoconstriction .
• Itraconazole appears to modify the immunologic activation associated with allergic bronchopulmonary aspergillosis and to reduce the number of exacerbations but there is no significant change in lung function .Oxatomide, an anti-histamine agent, seems to have no effect on asthma control, although the evidence is insufficient .There is insufficient evidence to recommend either the use or avoidance of vitamin C supplements in the treatment or management of asthma .

Physiotherapy and rehabilitation

• Physical endurance-type training may improve cardiopulmonary fitness of asthmatic subjects and might possibly have positive effects on health-related quality of life .
• Breathing exercises may have positive effects on asthma symptoms and quality of life in adults with asthma .

Psychological interventions

• There is insufficient evidence for conclusions concerning the role of psychological interventions in asthma .

Lifestyle and counselling

Chronic asthma may improve with reducing calorie intake but the evidence is very limited .
• Caffeine may improve airways function modestly for up to four hours in people with asthma .
• Supplementation of diet with marine n-3 fatty acids seems not to improve asthma symptoms, although the evidence is insufficient .Culture specific asthma education programmes may be better than generic programmes in improving quality of life in adults and asthma knowledge in children but they seem not to significantly improve asthma exacerbation rates .

Others

• There is no overall improvement of asthma following treatment of gastro-oesophageal reflux. Subgroups of patients may gain benefit, but it appears difficult to predict responders .
• Tailored asthma interventions based on sputum eosinophils appears to be beneficial in reducing the frequency of asthma exacerbations in adults with frequent exacerbations and severe asthma .
• The use of room air ionisers may not reduce symptoms in patients with chronic asthma .
• Influenza vaccine seems unlikely to worsen asthma, but research is needed to determine whether asthma attacks are prevented by influenza vaccination .
• There is insufficient evidence to compare the effectiveness of holding chambers versus nebulisers in chronic asthma .

Other evidence summaries

• Antihistamines appear to have only a small beneficial effect on adult asthma. They cause more sedation than placebo .
• Self management appears to reduce incidents caused by asthma and improve quality of life .

Clinical guidelines

• British guideline on the management of asthma. British Thoracic Society (BTS) / Scottish Intercollegiate Guidelines Network (SIGN). Guideline No. 141, October 2014
Sveum R, Bergstrom J, Brottman G, et al. Diagnosis and management of asthma. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012.

Literature

Clinical practice reviews

• Rees J. Asthma control in adults [Clinical review]. BMJ 2006 Apr 1;332(7544):767-71.