Long-acting reliever inhalers
If your asthma does not respond to initial treatment, the dose of preventer inhaler you take may be increased in agreement with your healthcare team.
If this does not control your asthma symptoms, you may be given an inhaler containing a medicine called a long-acting reliever (long-acting bronchodilator/long-acting beta2-agonist, or LABA) to take as well.
These work in the same way as short-acting relievers. Although they take slightly longer to work, their effects can last for up to 12 hours. This means that taking them regularly twice a day provides 24-hour cover.
Regular use of long-acting relievers can also help reduce the dosage of preventer medication needed to control asthma. Examples of long-acting relievers include formoterol and salmeterol, and recently vilanterol, which may last up to 24 hours.
However, like short-acting relievers, long-acting relievers do not reduce the inflammation in the airways. If they are taken without a preventer, this may allow the condition to get worse while masking the symptoms, increasing the chance of a sudden and potentially life-threatening severe asthma attack.
You should therefore always use a long-acting reliever inhaler in combination with a preventer inhaler, and never by itself.
In view of this, most long-acting relievers are prescribed in a "combination" inhaler, which contains both an inhaled steroid (as a preventer) and a long-acting bronchodilator in the one device.
Examples of combination inhalers include Seretide, Symbicort, Fostair, Flutiform and Relvar. These are usually (but not always) purple, red and white, or maroon.
Other preventer medicines
If regular efficient administration of treatment with a preventer and a long-acting reliever still fails to control asthma symptoms, additional medicines may be tried. Two possible alternatives include:
- leukotriene receptor antagonists – tablets that block part of the chemical reaction involved in the swelling (inflammation) of the airways
- theophyllines – tablets that help widen the airways by relaxing the muscles around them, and are also relatively weak anti-inflammatory agents
If your asthma is still not under control, you may be prescribed regular steroid tablets. This treatment is usually monitored by a respiratory specialist (an asthma specialist).
Oral steroids are powerful anti-inflammatory preventers, which are generally used in two ways:
- to regain control of asthma when it is temporarily upset – for example, by a lapse in regular medication or an unexpected chest infection; in these cases, they are typically given for one or two weeks, then stopped
- when long-term control of asthma remains a problem, despite maximal dosages of inhaled and other medications – in these cases, oral steroids may be given for prolonged periods, or even indefinitely, while maintaining maximum treatment with inhalers as this maximises the chance of being able to stop the oral steroids again in the future
Long-term use of oral steroids has serious possible side effects, so they are only used once other treatment options have been tried, and after discussing the risks and benefits with your healthcare team.
See below for more information on the side effects of steroid tablets.
Omalizumab, also known as Xolair, is the first of a new category of medication that binds to one of the proteins involved in the immune response and reduces its level in the blood. This lowers the chance of an immune reaction happening and causing an asthma attack.
It is licensed for use in adults and children over six years of age with asthma.
The National Institute for Heath and Care Excellence (NICE) recommends that omalizumab can be used in people with allergy-related asthma who need continuous or frequent treatment with oral corticosteroids.
Omalizumab is given as an injection every two to four weeks. It should only be prescribed in a specialist centre. If omalizumab does not control asthma symptoms within 16 weeks, the treatment should be stopped.
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Bronchial thermoplasty is a relatively new procedure that can be used in some cases of severe asthma. It works by destroying some of the muscles surrounding the airways in the lungs, which can reduce their ability to narrow the airways.
The procedure is carried out either with sedation or under general anaesthetic. A bronchoscope (a long, flexible tube) containing a probe is inserted into the lungs through the mouth or nose so it touches the airways.
The probe then uses controlled heat to damage the muscles around the airways. Three treatment sessions are usually needed, with at least three weeks between each session.
There is some evidence to show this procedure may reduce asthma attacks and improve the quality of life of someone with severe asthma.
However, the long-term risks and benefits are not yet fully understood. There is a small risk it will trigger an asthma attack, which sometimes requires hospital admission.
You should discuss this procedure fully with your clinician if the treatment is offered.
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