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Medical Author:

George Schiffman, MD, FCCP

George Schiffman, MD, FCCP

Dr. Schiffman received his B.S. degree with High Honors in biology from Hobart College in 1976. He then moved to Chicago where he studied biochemistry at the University of Illinois, Chicago Circle. He attended Rush Medical College where he received his M.D. degree in 1982 and was elected to the Alpha Omega Alpha Medical Honor Society. He completed his Internal Medicine internship and residency at the University of California, Irvine.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Controller medications are for long-term control of persistent asthma. They help to keep airways open and reduce the inflammation in the lungs that underlies asthma attacks. Controller medications include long-acting beta-agonists and anti-inflammatory medicines.

Long-acting beta-antagonists: This class of drugs is chemically related to adrenaline, a hormone produced by the adrenal glands. Inhaled long-acting beta-agonists work to keep breathing passages open for 12 hours or longer. They relax the muscles of the breathing passages, dilating the passages and decreasing the resistance to exhaled airflow, making it easier to breathe. They also may help to reduce inflammation, but they have no effect on the underlying cause of the asthma attack. Side effects include rapid heartbeat and shakiness. Salmeterol (Serevent) and formoterol (Foradil) are long-acting beta-agonists.

Anti-inflammatory medicines minimize the inflammation that underlies an acute asthma attack. Generally these medications do not help during an attack, but you should continue to take them during an attack.

• Inhaled corticosteroids are the main class of medications in this group. The inhaled steroids act locally by concentrating their effects directly within the breathing passages, with very few side effects outside of the lungs. Beclomethasone (Vancenase, Beclovent), fluticasone (Flovent), budesonide (Pulmicort), and triamcinolone (Azmacort) are examples of inhaled corticosteroids.



• Other anti-inflammatory drugs used to treat asthma include oral steroids, leukotriene inhibitors, methylxanthines, and cromolyn sodium. For more information about these medications, see Asthma and Understanding Asthma Medications.

Rescue medications are bronchodilators. They quickly open the airways closed off by swelling, bronchospasm, and mucus. These are taken after an asthma attack has already begun. These do not take the place of anti-inflammatory drugs. Do not stop taking your anti-inflammatory drug(s) during an asthma attack.

• Short-acting beta2-agonists are the most commonly used rescue medications. This class of drugs is chemically related to adrenaline, a hormone produced by the adrenal glands. Inhaled beta2-agonists work rapidly (within minutes) to open the breathing passages. They relax the muscles of the breathing passages, dilating the passages and decreasing the resistance to exhaled airflow, making it easier to breathe. They do not reduce inflammation and have no effect on the underlying cause of the asthma attack. Side effects include rapid heart beat and shakiness. Albuterol (Proventil HFA, Ventolin HFA, ProAir) is the most frequently used beta2-agonist medication.



• Anticholinergics are another class of drugs useful as rescue medications during asthma attacks. Inhaled anticholinergic drugs open the breathing passages, similar to the action of the beta2-agonists. Inhaled anticholinergics take slightly longer than beta2-agonists to achieve their effect, but they last longer than the beta2-agonists. An anticholinergic drug is often used together with a beta2-agonist drug to produce a greater effect than either drug can achieve by itself. Ipratropium bromide (Atrovent) is the inhaled anticholinergic drug currently used as a rescue asthma medication.



• Tiotropium (Spiriva), a long-acting anticholinergic, is now also being used as a maintenance medicine in more severe cases of asthma.



• Combination therapy which includes a long-acting beta2 agonist and inhaled corticosteroid available in a single inhaler is now commonly used in asthma (for example, Advair, Symbicort, Dulera).

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