9. Asthma Medications

Types of Inhalers

Asthma device quick guide - this is a printable guide to different common medication device systems and technique.

Spacer Devices

Utilization of spacer devices is crucial with metered dose inhalers (MDI) and ensure delivery of medications to lower airways. Patients should ideally be at least 10 years old and able to use proper technique for mouthpiece. Proper use should be educated and assessed with every encounter. Cleaning instructions are also included in the following video and handouts.

There are multiple types of spacer devices available. At Children’s Mercy, we use the brand AeroChamber Plus® with mouthpiece or mask setup. Other options include: OptiChambers® and Vortex®. Paper spacers are also available as a disposable option.

Most insurance companies will cover 1 spacer every 6-12 months. Some insurance companies may require this prescription to be sent as a durable medical device.

Asthma pharmacotherapy

High-Level Overview of Asthma Medications by Class

Short-Acting Beta Agonists (SABA)

Quick relief medications for bronchodilation. Most commonly albuterol and levalbuterol in the US.

Available SABAs

Inhaled Corticosteroids (ICS)

The cornerstone of asthma therapy is to maintain asthma control. There are a variety of brands and modalities with their own risks and benefits.

Of significance to pediatrics, one must consider low, medium, and high doses in comparison to the patient’s age. Comparative dosing for under age 5 is limited. A table for comparative dosing by age is available below.
Alvesco® (ciclesonide) is sometimes used for children with asthma who have concerns for adrenal insufficiency or growth failure.

Available ICS

Concomitant Therapy

The EPR4 provided the option of concomitant therapy for asthma in children with intermittent asthma over age 5 or as an alternative therapy in mild persistent asthmatics. Concomitant therapy is defined as the use of an inhaled corticosteroid (ICS) at the same time a SABA is used and both medications can be done together as needed. This can be done with two separate inhalers or AirSupra®, which is a combination of ICS/SABA depending on age. AirSupra at this time is available for 18 and above.

AirSupra

Inhaled Corticosteroids and Long-Acting Beta Agonists (ICS/LABA)

ICS/LABA are a class of combined medication inhalers including corticosteroid and a long-acting beta agonist. Please see the table below for a full list of available medications in the United Sates.

LABAs most used in the US are salmeterol, formoterol, and vilanterol.
LABAs should not be used alone in asthma management as this increases risk of death.

Available ICS/LABA

Single Maintenance and Reliever Therapy (SMART)

ICS-formoterol combination inhalers can be prescribed for maintenance therapy, and the same inhaler can also be used as needed for symptom relief.
- Budesonide/formoterol (generic and the brand name version Symbicort®) and mometasone/formoterol (Dulera®) are the only US approved medications for SMART
Formoterol has an onset of action within 3-5 minutes and lasts up to 12 hours.
Approved therapy for 4 years of age and up
Maximum dosing per 24 hours
- Ages 4-11 = 8 puffs
- Ages 12+ = 12 puffs
When compared to albuterol only, SMART resulted in fewer exacerbations and a decrease in severity of reactions.
Considerations should be given to an emergency albuterol inhaler to be kept in home and/or school for when ICS-formoterol is unavailable.

Anti-Muscarinic/ Anti-Cholinergic Agents for Asthma

The use of anti-muscarinic agents is discussed in EPR4 and they recommend:

Adding a long-acting muscarinic antagonist (LAMA) to inhaled corticosteroids-long-acting beta agonist (ICS/LABA) in Step 5 or higher above age 6.
Adding a LAMA to ICS for those who cannot use a long-acting beta agonist (LABA) as an alternative therapy in children over age 12 in step 3 or higher.

The use of anti-muscarinic agents is discussed in EPR4 to recommend:

Adding LAMA to those uncontrolled on ICS/LABA
Against adding to ICS alone
Against using LAMA without ICS

Available LAMA/ Anti-Colinergics

Leukotriene Receptor Antagonists (LTRA)

Montelukast (Singulair®)
- FDA Black Box warning in March 2020 due to risk of neuropsychiatric events including behavior changes, mood changes, agitation, nightmares, night terrors, suicidal thoughts and actions. Therefore, the FDA now recommends that montelukast only be used to treat patients with allergic rhinitis that do not respond to alternative medications. Careful assessment regarding risks and benefits of montelukast is recommended for initiation and continuation.
Zafirlukast
- Available for asthma from age 5 years and older
- Potential side effect of liver damage – monitor hepatic enzymes closely
- Administer twice daily and 1 hour before or 2 hours after a meal
Zileuton (Zyflo®)
- Used for mild to moderate asthma in patients >12 years of age
- Does not work as a rescue medication
- Inhibits leukotriene formation
- Original formulation dosing is 600mg tablet 4 times per day which limits its use in pediatrics
- Zyflo CR extended-release dosing is 1200mg twice daily and should be taken 1 hour after meals
- Serious side effects include elevation of liver enzymes resulting in the need for hepatic function monitoring for the first 3 months, then quarterly for a year, then annually.
- Additional side effects include sleep and behavior changes
- Drug interactions include: theophylline, propranolol, caffeine, and possible warfarin level increase.

Available LTRA

Macrolide antibiotics: Azithromycin

Macrolide antibiotics are sometimes used for their anti-inflammatory effects in asthma. The use of azithromycin is not discussed in the EPR-3 or EPR-4. In GINA, patients may be prescribed a 6 month trial of azithromycin 3 times a week for prevention or at onset of illness in the yellow zone.

Azithromycin

Oral Steroids

Oral steroids are often used for the treatment of acute asthma exacerbation or occasionally used chronically in severe asthma.

Available Oral Corticosteroids