Asthma Management and Prevention Medications

Short-Acting Beta2-Agonists (SABA)

SABA (e.g., salbutamol/albuterol) provides quick relief of symptoms and bronchoconstriction. While widely used in emergency settings, regular or frequent use of SABA is associated with increased airway inflammation and a higher risk of death.

Anti-inflammatory Reliever (AIR)

A preferred modern approach, especially for adults and adolescents, is Anti-inflammatory Reliever (AIR) therapy. This involves using a combination of an ICS and a rapid-acting bronchodilator, such as formoterol.

The advantage of AIR is that every time a patient reaches for their reliever to treat symptoms, they are also receiving a dose of anti-inflammatory medication, which helps prevent the underlying inflammation from worsening.

Maintenance Strategies: LABA, LAMA, and MART

For patients whose asthma is not controlled by low-dose ICS alone, clinicians may escalate therapy using different combinations.

Long-Acting Beta2-Agonists (LABA)

LABA medications are used in combination with ICS to provide long-term bronchodilation. It is important to note that LABA should never be used as monotherapy in asthma; they must always be paired with an ICS to ensure inflammation is addressed.

Long-Acting Muscarinic Antagonists (LAMA)

LAMA can be added to a regimen of ICS-LABA for patients who remain uncontrolled. While adding a LAMA may only provide a small improvement in lung function and exacerbation rates, it can be a valuable tool for Step 4 treatment.

Maintenance-and-Reliever Therapy (MART)

MART (also known as SMART) is a specific dosing strategy using a single inhaler containing an ICS and a rapid-acting LABA (like formoterol). In this regimen, the patient uses the same inhaler for both their daily maintenance doses and their as-needed symptom relief.

Specialized and Advanced Therapies

Leukotriene Receptor Antagonists (LTRA)

LTRA are an alternative class of oral medications that can be used in asthma management.

Systemic Corticosteroids

For severe acute exacerbations, Systemic Corticosteroids (such as prednisone or prednisolone) are highly effective at preventing the recurrence of an attack. However, long-term use should be avoided as a last resort due to serious side effects like osteoporosis, diabetes, and hypertension.

Biologics (Targeted Therapies)

For patients with severe asthma that remains uncontrolled despite high-dose ICS-LABA, biologic therapies targeting specific inflammatory pathways may be used:

• Anti-immunoglobulin E (Anti-IgE): Targets allergic asthma (e.g., omalizumab).
• Anti-interleukin 5 (Anti-IL-5): Targets eosinophilic asthma (e.g., mepolizumab, benralizumab).
• Anti-interleukin 4 receptor alpha: Targets Type 2 airway inflammation (e.g., dupilumab).
• Anti-thymic stromal lymphopoietin (Anti-TSLP): A newer target for severe asthma (e.g., tezepelumab).

Summary Table of Medication Classes