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Asthma: Medications and Other Therapies

for Health Care Providers

Table 3: Medications and Other Therapies

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For acute symptoms and exacerbations
SABA (eg, albuterol, levalbuterol)
  • Mainstay of therapy for intermittent disease
  • Via nebulizer (eg, 0.083% albuterol solution) or metered-dose inhaler (MDI) (90 mcg/puff)
  • For symptoms: PRN
  • For exacerbation: 4-8 puffs every 20 min x 3, then Q1-4H PRN
Anticholinergic bronchodilators (eg, ipratropium)
  • Adjunct to beta-agonists
  • Via nebulizer (0.03% solution), or MDI (18 mcg/puff,
    2 puffs), 4-8 puffs every 20 minutes for up to 3 hours
Systemic corticosteroids (prednisone or equivalent)
  • For mild exacerbation, prednisone 40-60 mg QD for 5-10 days
  • For more severe exacerbations, prednisone 40-80 mg QD until PEFR reaches 70% personal best/predicted
  • Methylprednisolone 60-125 mg IV Q6-12H for severe exacerbations
For long-term control
Inhaled corticosteroids (ICS); in order of increasing potency (on mg per mg basis):
  • Triamcinolone = flunisolide
  • Beclomethasone = budesonide
  • Fluticasone
  • Mainstay of therapy for mild disease or greater
  • See Pharmacy Benefits Management page for dosing summary
  • Start with beclomethasone 200 mcg BID or equivalent
  • Use lowest dose consistent with disease control
  • Adding LABA is superior to doubling ICS dose
LABA (eg, formoterol, salmeterol)
  • Not appropriate for monotherapy; may mask exacerbation
  • Administer via dry powder inhaler (DPI)
  • Dosage: formoterol 12 mcg Q12H; salmeterol 50 mcg Q12H
Leukotriene receptor antagonists (eg, montelukast, zafirlukast)
  • Potential alternative to low-dose ICS for patients with mild asthma unable to use MDI or DPI, or as adjunct to ICS for patients with moderate persistent asthma
  • Montelukast has not been shown to inhibit CYP 3A4, whereas zafirlukast may inhibit CYP 3A4 and 2C9, potentially interacting with PIs
Mast cell inhibitors (cromolyn, nedocromil)
  • Potential alternative to low-dose ICS for patients with mild asthma unable to use MDI or DPI, or as adjunct for ICS in patients with moderate persistent asthma
  • Dosage: 2 puffs QID
  • Use discouraged because of drug-drug interactions and narrow therapeutic index
  • Use only with patients who show clinical benefit
  • Dose using extended-release form; follow levels closely (target level 5-15 mcg/mL)
  • Initial dosage: 300 mg QD in 2-3 divided doses; a dose increase of 1 mg/kg will increase levels by 2 mcg/mL
  • Decrease by 50% in patients with liver dysfunction
  • Reserved for patients with elevated serum IgE
  • Use restricted to Pulmonary or Allergy/Immunology services
Oral corticosteroids
  • 7.5-60 mg QD (or dosed QOD to decrease adrenal suppression)
For prevention of exercise-induced bronchospasm
  • Use SABA just before exercise; alternatively, use LABA 15 minutes (formoterol) or 30 minutes (salmeterol) before exercise

From Asthma
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009