Many asthmatics need regular ‘preventive’ medication to keep their asthma under control. A rule of thumb is that any patient who needs to use their ‘quick-relief’ medication daily or more than three to four times a week should be started on daily long-term preventive medication.

Preventive medication also reduces exacerbations and hospitalization due to asthma. It is therefore considered wise that no patient admitted to the hospital for an acute exacerbation of asthma should be discharged without preventive medication.

Currently, the most effective and potent drugs for the management of asthma are corticosteroids. For long-term management, regular inhaled corticosteroids offer the most effective way of managing asthma today.

The long-acting bronchodilators are presently classified as ‘preventive’ medication for asthma. They ensure sustained bronchodilation for up to 12 hours.

The indications for use of long-acting bronchodilators include the following:

1. For improving control of nocturnal and exercise-induced asthma.
2. As ‘add-on’ therapy to inhaled steroids in asthma. Studies have shown that the addition of a long-acting bronchodilator to low dose inhaled steroids may be more effective than simply doubling the dose of inhaled steroid.
3. As regular bronchodilators for COPD.

Inhaled steroid and long-acting bronchodilators, used together, combat 2 components of asthma - the inflammatory and the bronchospastic. Studies have shown that the addition of regular bronchodilator to inhaled steroids in asthma contributes further to the well being of the patient.

Studies have also shown that the addition of a long-acting bronchodilator in the therapeutic regimen (already consisting of inhaled steroids) may allow a lower dose of inhaled steroid to be used regularly. This would be even more safe.

Currently, it is recommended to initiate therapy with inhaled steroids as early as possible in patients with persistent symptoms. Studies have shown that the longer one delays the institution of inhaled steroids in asthma, the less the quantum of benefit.

When starting inhaled steroids, current opinion seems to favour starting with moderate-to-high doses. This has two advantages:

1. It enables rapid control of airway inflammation, thus getting the underlying disease under control.
2. It improves the confidence of the patient in his treatment, which subsequently improves compliance.

Once treatment is initiated with a particular dose (e.g. 800 mcg of budesonide), that dose needs to be maintained for at least 3 months. Thereafter, a gradual reduction (approximately 25-50%) every month) may be done by monitoring symptoms and peak flow rates.

Regular inhaled steroids reduce asthma symptoms and exacerbations of the disease. By this, hospitalisations are significantly reduced due to this disease. School absenteeism (in children) and work absenteeism (in adults) is markedly reduced.

Lung function, in addition, is maintained at normal or ‘near-normal’ levels. All the above allow the asthmatic to lead a normal life, just like any other person. It is in this respect that inhaled corticosteroids have contributed enormously to improving the quality of life of asthmatics.

Inhaled steroids are safe to use in even pre-school children. Barring fluticasone (which is currently recommended only over the age of 4 years), beclomethasone and budesonide can be safely used even in young pre-school children. In recommended doses, inhaled steroids rarely cause growth retardation. In fact, uncontrolled asthma in a child is a far greater risk for growth retardation than that due to steroids.

Inhaled salmeterol and formoterol can both be used in children over the age of 4 and 5 years respectively. Exercise-induced asthma, nocturnal asthma and as ‘add-on’ to inhaled steroid therapy are the main indications.

Theophylline is a very weak bronchodilator. New evidence points to some anti-inflammatory effects of theophylline. Theophylline is mainly considered in its sustained-release formulations for once or twice daily administration in asthma. Being an oral drug, compliance with therapy may be better than with inhaled therapy; however the side-effects are significant, especially when used in high doses.

In acute severe asthma, the role of intravenous aminophylline is only secondary now to nebulised b₂-agonists. In a patient who fails to respond to both nebulised b₂-agonist and ipratropium bromide, an aminophylline infusion may be commenced.

Sustained-release oral theophylline has important beneficial effects on diaphragmatic contractility. These effects may be extremely useful in patients with COPD.

There is no such device as an ‘ideal’ inhaler. Both MDIs and DPIs are equally effective in delivering medication when used correctly by the patient.

Nebuliser is the device of choice when medication has to be delivered for an acute severe attack of asthma.

If the level of understanding and co-operation of the patient is low, dry powder inhalers (e.g. Rotahaler) are preferred, as they are both easy to teach and use. They also are economical with a low initial cost.

As far as age is concerned, children below 5 years have 2 options for regular use:

1) MDI + Spacer (with or without attached face mask) OR
2) Nebulisers

Above the age of 5 years (and adults), the options for regular use are either:

1) MDI (with or without spacer) OR
2) DPI (Rotahaler)

Nebulisers rarely need to be used regularly in these patients.

Patient education is the base of asthma management. It is important that proper communication occurs between the physician and the patient on certain important issues such as:

• Explanation of the ‘chronic’ nature of the disease
• Emphasis on ‘control’ and not ‘cure’
• Differentiation between ‘quick-relief’ and ‘preventive’ medication
• Training in correct technique of using inhaler device; checking the same on follow-up
• Allaying any fears and concerns of the patient
• Maintenance of treatment diaries and home peak flow monitoring in select patients who can be expected to do so.

There are no contraindications to the use of inhaled corticosteroids in active pulmonary TB, so long as these patients are concomitantly receiving anti-tubercular chemotherapy as well. Similarly, there is no harm in the regular use of inhaled corticosteroids in immunocompromised patients, as long as opportunistic infections are detected early and treated appropriately.

Allergic rhinits is frequently associated with asthma and often acts as a trigger for exacerbations of the disease. Mild, infrequent episodes may need treatment with only need-based antihistamines and at times, decongestants.

When symptoms become frequent and persistent, regular topical anti-inflammatory agents are required such as nasal cromoglycate or nasal steroids.

Nasal steroids are the most effective way of managing chronic allergic rhinitis. In the presence of nasal polyposis, these agents (in higher doses) can even reduce the polyp size and avoid surgery in many patients.