9 modern medications for asthma

*Review of the best according to the editorial board. About the selection criteria. This material is subjective, not an advertisement and does not serve as a guide to purchase. It is necessary to consult a specialist before making a purchase.

Proper diagnosis and treatment of bronchial asthma is a serious problem of modern pulmonology. Asthma is a multifaceted disease. On the one hand, it is chronic inflammation of the bronchial tree, with an abundance of symptoms such as shortness of breath on exhalation, that is, expiratory dyspnea, various wheezing and coughing, a feeling of stuffiness in the chest.

Such symptoms appear from time to time, are of varying intensity, and are associated with an exacerbation of bronchial asthma, which typically proceeds as an attack of choking, alternating with interictal periods.

Many patients with bronchial asthma have a marked association with allergies. This is the most common type of asthma, which is determined as early as childhood. In such patients, drug or food allergies, atopic dermatitis, diathesis are determined from a very young age. There is marked eosinophilia in the sputum of these patients, and individuals with the allergic type have a good response to treatment with hormonal agents, especially in the form of inhalation. There are other types of bronchial asthma, which we will not dwell on here. It requires a long time, comprehensive diagnosis including spirometry, immunologic and allergologic testing.

Asthma risk factors

However, in all cases it is essential to look for environmental factors which may be involved in the asthma. In addition to allergens such as dust mites, animal hair, fungi, plant pollen – it is very important to identify infectious factors such as frequent viral diseases. Occupational hazards are important, as well as harmful volatile substances. These include tobacco smoke, sulfur dioxide, gasoline and diesel combustion products.

A very important risk factor appears to be improper nutrition. Patients with asthma usually consume a lot of foods that have the highest degree of cooking and few antioxidants on the way out. Such patients eat little vegetables, fruit, fiber, and fatty varieties of fish. But fast food, smoked meats, and canned foods are prevalent.

In the diagnosis of bronchial asthma in adults, it is very important to pay attention to the following symptoms, which significantly increase the likelihood of such a diagnosis. These are the following signs:

1. Occurrence of chest congestion;
2. choking;
3. Coughing, especially during the night and early morning hours;
4. provocation of similar symptoms by cold air, physical exertion or various allergens

increased symptoms of choking and coughing after taking acetylsalicylic acid, or aspirin, beta-adrenoblockers, which are used to relieve tachycardia and treat coronary heart disease;

1. The presence of asthma or atopic diseases in relatives;
2. A large number of dry, wheezing rales;
3. Low spirographic values, such as peak expiratory velocity;
4. high number of eosinophils in peripheral blood.

Treatment of bronchial asthma is a staged process, and modern medicine knows a total of five consecutive stages of treatment. What is the treatment?

About routine and emergency asthma treatment

Treatment of bronchial asthma (especially remitting and mild) begins with the first step. If it is not effective, therapy is intensified and the patient is transferred to the second stage. Similarly, if treatment in the second step is ineffective, the medications are gradually replaced, other agents are added, doses are increased, and finally, the patient is selected for a specific treatment regimen.

Once the course of bronchial asthma is under control at this stage, and the attacks are eliminated, you can gradually reduce the amount of treatment until you have reached the optimal minimum set of drugs which either do not cause an attack at all, or they do not occur more than once a week. This treatment of bronchial asthma is called a selection of basic therapy. It is carried out, selected, and optimized for the individual patient outside the condition of attacks.

However, there is a second side of bronchial asthma treatment. This is the actual management of a bronchial asthma attack, which is done according to slightly different rules. It is the combination of both seizure management and interictal treatment that forms the basis of modern asthma therapy.

Let’s take a look at the main medications that are designed to provide emergency care, and to stop a bronchial asthma attack that has developed. It goes without saying that these medications, selected in collaboration with a pulmonologist, should always be on hand for the patient to apply at any time of the day when alarming symptoms occur.

All medications described in this material are not relevant to the rating, and their sequence is dictated only by the form of presentation. The drug name consists of the international nonproprietary name (INN). Then comes the name of the original drug that was first marketed under its own name. This is usually the most expensive remedy, the price “flagship” of the line. Next are the commercial copies, or generics. The price is usually given for the original drug, ranging from the cheapest to the most expensive, and is relevant for pharmacies of all forms of ownership for August 2019 in the Russian Federation.

Overview of asthma medications

Emergency therapy: Dealing with asthma attacks

First of all, you need to define what an exacerbation, or asthma attack. Is a condition in which the patient gradually develops a cough, with increased wheezing, shortness of breath and chest congestion. It is important to remember that exacerbations may develop not only in a patient with an already diagnosed asthma, but may also be the very first symptom of a newly emerging disease.

A bronchial asthma attack can occur in any patient with this diagnosis, regardless of severity, even in patients with mild. A typical attack can develop at different rates, sometimes it takes a few minutes to develop, and sometimes the symptoms build up over a long period of time, even up to 2 weeks.

Resolution, or attenuation of an exacerbation, also takes a long time, from a few days to the same 2 weeks. Exacerbations of bronchial asthma are quite serious. It is known that in any hospital that has an emergency department, about 12% of all admissions are bronchial asthma attacks, and about 5% of all admissions with this diagnosis need to be admitted directly to the intensive care unit.

Clear and understandable criteria for severity during a seizure are respiratory rate, which in a severe seizure exceeds 25 breaths-exhalations per minute, increased pulse rate, which in the same severe seizure exceeds 110 beats per minute. An important diagnostic criterion is the inability to utter any sentence, or phrase on one exhalation. In the case of a drop in blood pressure, the development of bradycardia, the appearance of bruising of the skin, or cyanosis, a drop in capillary oxygenation of less than 92% – we are talking about a life-threatening attack, and such a patient is admitted to the intensive care unit on a mandatory basis.

How to treat a bronchial asthma exacerbation? First of all, it is the prescription of fast-acting bronchodilators, which are agonists of beta-2 adrenoreceptors. Then the use of anticholinergic drugs, as well as the combination of these two groups of drugs, which with a high level of evidence increase the rapid resolution of an asthma attack and reliably reduce mortality. Finally, the main treatment of an exacerbation may require the early use of glucocorticosteroids, both as systemic administration and inhalation, as well as oxygen therapy. Consider the main medications used to relieve a bronchial asthma attack.

Bronchodilators – inhaled beta-2 agonists: Salbutamol (Ventolin)

Popularity rating:* 4.9

β-2 adrenoreceptor agonists, used in nebulized, or inhaled form, are the most economical, and optimal method of managing patients with bronchial asthma in the presence of a mild to moderate attack.

Ventolin affects the bronchial smooth muscle adrenergic receptors (β-2), while having no effect on the similar myocardial receptors, which are called β-1. This leads to a marked dilation of the bronchi, which stops an attack of bronchial asthma. Salbutamol-Ventolin use in particular reduces airway resistance, increases lung capacity, and activates the atrial fibrillation epithelium. It improves mucus secretion and secretion, which is very important in preventing respiratory infections.

Inhaled forms of salbutamol act very quickly: the beginning of the effect develops in 5 minutes, and after another 5 minutes the effect increases to 75% of the maximum, and the duration of action is up to 6 hours. However, it is necessary to apply this drug more than once, and strictly follow the instructions of the treating pulmonologist. Ventolin is indicated primarily to relieve the attack and then as a prophylactic measure to prevent bronchospasm, e.g. after ingestion of a known allergen, when exposed to freezing air or during exercise, when an attack has previously occurred in similar conditions. It is also possible to use salbutamol in complex therapy not only in the presence of exacerbations, but also for long-term treatment of bronchial asthma during the interictal period.

Bronchodilators should be used fairly frequently. But in the case of Ventolin, the manufacturer does not recommend using it more than 4 times a day. The recommended dose to relieve an attack of bronchial asthma is usually one or two inhalations, i.e. 100 to 200 g of salbutamol.

Produces Ventolin company Glaxo Wellcome, in an aerosol can for metered inhalation. There are 100 mcg of salbutamol per nebulized dose, one aerosol can is designed for 200 doses. The cost of one pack is from 107 to 136 rubles.

Advantages and disadvantages

The advantages of all short-acting inhaled β2-receptor agonists are their rapid effect, the ability to use them for prophylactic purposes, and the ability to prescribe them for obstructive bronchitis without a diagnosis of bronchial asthma. This drug is on the List of Vital and Essential Medicines (VED) and is therefore inexpensive. However, salbutamol and its analogues must be inhaled several times, and there are contraindications to the use of salbutamol in children under two years of age. Despite the selectivity of action, the drug is used with caution in various cardiac pathologies, thyrotoxicosis, pregnancy, breastfeeding, and decompensated diabetes mellitus. There are also various drug interactions.

ACP: Ipratropium bromide (Atrovent-N)

Popularity Rating:* 4.8

Anticholinergic drugs (ACP) are derivatives of atropine, their function is to block specific cholinoreceptors of bronchial smooth muscle. As a result, bronchial mucosa dries out and mucosal secretion decreases due to inhibition of the effect on bronchial glands. Anticholinergic drugs effectively dilate the bronchi, and prevent their narrowing, especially due to the effects of cold air, cigarette smoke, relieve spasm associated with parasympathetic effects of the X pair of cranial nerves. A major representative of this class of drugs used to relieve a bronchial asthma attack is ipratropium bromide (Atrovent-N). The effect of expanding the bronchi develops after 10 minutes, the maximum development after 2 hours, and the duration of action – up to 6 hours.

Atrovent-N is used for relieving attacks of bronchial asthma of mild to moderate severity. Atrovent-N is especially recommended if a patient has a concomitant lesion of the cardiovascular system. It is also indicated for the treatment of chronic obstructive pulmonary disease. Use Atrovent-N in the form of aerosol for adults in 2 doses up to 4 times a day, and in the case of an attack of bronchial asthma, you can increase the dose up to 12 times a day, but first all this must be agreed with the doctor.

Atrovent-N aerosol dosed for inhalation, contains 200 doses in a 10 ml can, each dose contains 20 micrograms of ipratropium bromide. Produces Atrovent-N by the German company Boehringer Ingelheim, and the cost of one balloon ranges from 300 to 380 rubles.

Advantages and disadvantages

The big plus of Atrovent can be considered the absence of overdose. In order to really poison the body with ipratropium, you need to inhale about 500 doses at once. The systemic effects associated with anticholinergic symptoms are therefore very mild, which is why the remedy is recommended, including for patients with cardiovascular pathology. They do not develop the tachycardia, urinary retention, palpitations, dry skin and mucous membranes characteristic of atropine exposure. However, in some cases, patients may experience coughing, urticaria, and allergic reactions. If a patient has an attack of suffocation very quickly, it is necessary to use salbutamol first, and Atrovent second, since the effect of expanding the bronchi is more likely to develop with beta-adrenoreceptor stimulants, and only then with Atrovent and its analogues.

ipratropium bromide + fenoterol (Berodual, Astmasol, Inspirax)

Popularity rating:* 4.7

The product combines β2-adrenomimetic and atropine derivative in one bottle, so to speak, in order not to use salbutamol and ipratropium bromide in turns and not to carry them in different pockets. Only instead of salbutamol its analogue, fenoterol, was taken. This combination may provide a more sustained and pronounced bronchodilator effect and eliminate an asthmatic attack than the separate use of these drugs. The combination of these agents in the pre-hospital phase leads to fewer hospitalizations, as improvement occurs before the arrival of the ambulance.

Berodual can also be used in chronic obstructive lung disease, in the presence of emphysema, and even in the second and third trimesters of pregnancy. Inhalation of Berodual in adults for an acute attack of bronchospasm can be from 1 ml, or 20 drops, to 50 drops, or 2.5 ml. The lowest recommended dose, i.e., 20 drops, is diluted with isotonic sodium chloride solution to 4 ml and completely inhaled with a nebulizer.

Berodual is produced by the German company Boehringer Ingelheim. 20 ml of Berodual solution for inhalations, with a minimum dose of 20 doses, is sold in pharmacies for the price of 230 to 270 rubles.

Advantages and disadvantages

The pluses of Berodual are the proven improvement and reduction in hospitalizations, a better pharmacoeconomic profile (two-in-one), low price. The disadvantage is the need to use a nebulizer, pre-dilution with isotonic solution, and some symptoms associated with fenoterol overdose. These are palpitations, tremors, changes in blood pressure, hot flashes, or feelings of heat.

Adenosinergic agents: Theophylline (Theotard, Theopec)

Popularity rating:* 4.6

Bronchodilator effect of theophylline occurs due to the blocking of phosphodiesterase, adenosine receptor binding and relaxation of internal organ muscles. At the same time, it increases the tone of the respiratory muscles, that is, the diaphragm and intercostal muscles, increases the supply of oxygen, that is, increases its oxygenation, and dilates the vessels of the lungs. Theophylline is used for bronchial asthma, pulmonary emphysema, obstructive bronchitis, and asthmatic status.

Currently, Theophylline and its analogues are widely used in developing countries, and in countries with a high level of medicine for some time Theophylline was in the second order drugs, it was displaced by modern beta-2 agonists and anticholinergic agents. But now theophylline is gradually coming back into use, and it is used to treat exacerbations of bronchial asthma and in the interictal period.

Teotard is available as retarded capsules, that is, with delayed release, which provide a uniform and prolonged action. One pack of 40 tablets of 350 mg each, will cost from 220 to 420 rubles. Theotard is produced by the Slovenian company KRKA. It can be used after meals, adults one tablet once a day in the evening, if you start treatment, and the maintenance dose is twice as much, twice a day. Dose must necessarily be adjusted during treatment, as determined by serum theophylline.

Advantages and disadvantages

Theophylline has a complex effect on blood circulation in the lungs and smooth muscles, but at the same time it can cause seizures, anxiety, stuffy nose, nausea and vomiting. It interacts with many medications, possibly overdose symptoms. The obvious disadvantage is the need to regularly determine the concentration of theophylline in blood serum, so only a doctor should prescribe this drug.

GCS: budesonide (Pulmicort, Benacort)

Popularity Rating:* 4.5

In the past, patients in whom β2-receptor agonists and other bronchodilators failed to terminate a bronchial asthma attack were prescribed glucocorticosteroid hormones, often systemically, via an intravenous route. Usually dexamethasone was administered at home, by the ambulance, and the same dexamethasone was injected in the pulmonology or emergency department. If the hospital was richer, then methylprednisolone. Prednisolone was then given in tablets after the seizure was stopped.

Both intravenous and oral routes are equally effective in the exacerbation of bronchial asthma, but, of course, the tablets simply will not have time to work in the sudden development of an attack. Prednisolone was prescribed to be given for a week, in tablets after the infusion was stopped. However, there are also inhaled corticosteroids – drugs that are used with metered-dose nebulizers, nebulizers, and are not inferior to infusions and injections of glucocorticosteroid hormones. In some cases, they are even superior to them in terms of speed of onset of effect and safety profile.

One such medication is budesonide, or Pulmicort. In addition to relieving bronchial asthma attacks, it is used in acute obstructive laryngitis, is available in suspension, and is indicated for long-term treatment of bronchial asthma as well as for relieving attacks. It should be administered individually, up to 4 mg per day for adults, for maintenance therapy. In the case of exacerbations, the dose is increased, but necessarily by prior agreement with a pulmonologist. Pulmicort Turbuhaler is produced by Astrazeneca company from Great Britain, and the powder for inhalation in 100 doses at the rate of 200 mg per dose costs from 400 to 750 rubles.

Basic treatment for asthma outside of attacks

We have already mentioned above the stepwise regimens for the treatment of bronchial asthma as a routine treatment when no attacks are involved. Since the same drugs are used at the first stage as for relieving attacks, i.e. β2-receptor agonists, and their combination with ipratropium bromide, low doses of inhaled corticosteroids, and they are also present at other stages of more serious treatment, we will not dwell on them. Consider only those more powerful and modern medications that appear at more advanced stages of treatment. Leukotriene receptor antagonists appear in the second step. What are these medications?

Leukotrienes blockers: montelukast (Singular, Almont, Glamont, Montelar, Singlon, Ectalust).

Popularity Rating:* 4.9

The active ingredient montelukast sodium refers to bronchodilators, but only to blockers of specific receptors called leukotriene. Their blockade allows interruption of the chronic inflammation that constantly keeps the bronchi in an anxious, hyperreactive state in this disease. As a result, spasm of bronchial smooth muscles decreases, migration of active leukocytes such as macrophages and eosinophils into the lungs decreases, secretion of mucus and inflammatory immunoglobulins secretory series also decreases.

The drug is highly active when taken orally, and after a single dose, the effect lasts for a long time. Montelukast (Singulair) is used for long-term treatment of bronchial asthma, including its aspirin form, as well as for the prevention of bronchospasm attacks. In some cases, this drug and its analogues are indicated for the treatment of seasonal allergic rhinitis, hay fever, that is, pollinosis. The drug should be used in the dosage indicated by the physician. However, according to current data, inhaled corticosteroids are still drugs that are more effective in the second step of treatment than leukotriene receptor antagonists prescribed instead.

Clearly, long-acting, planned therapy for bronchial asthma may not include agents of very rapid action, so you can get by with tablets, and even chewable tablets. For example, Singulair is available from the well-known pharmaceutical company Merck Sharp and Home in dosages of 4 mg per tablet, and 5 mg per tablet. It will cost from 1400 to 1700 rubles for a pack of 28 pills, 5 mg each.

Inhaled hormones + β-2 agonist: Budesonide + formoterol, Simbicort Turbucoler

Popularity rating:* 4.8

Moving further along the steps of bronchial asthma treatment, we meet a combination of an inhaled glucocorticosteroid drug together with the bronchodilator fenoterol, which is close in its action to salbutamol. Symbicort Turbukhaler is one of the most effective, but expensive, drugs.

Symbicort should be administered to patients under 6 years of age, with particular caution should be used against a background of pulmonary tuberculosis, various respiratory infections, diabetes mellitus and other diseases. This drug is not indicated, of course, for emergency seizure management, but exclusively for routine treatment, and it is effective in reducing the frequency and severity of exacerbations. However, some experts believe that this medication can also be successfully used to relieve attacks, but whether or not to do so should be consulted with your doctor. The combined effect of budesonide and fenoterol has been proven to be higher than the separate use of these drugs, and the reduction in the frequency of exacerbations of the disease, the increase in lung function and elimination of symptoms of bronchial asthma is also more pronounced compared to the separate use.

Simbicort should be used at higher levels of treatment, and it is not intended to be used to start asthma treatment, for the first time, and especially for mild asthma. Usually before a patient is prescribed Symbicort, he has already gone through both beta-adrenomimetics, ipratropium bromide, and isolated hormones, all of which have not achieved their goal. The patient may even have been taking leukotriene antagonists. The selection of the dose is a matter for the attending pulmonologist, it should be the smallest, but, nevertheless, the doctor and the patient should monitor the symptoms of bronchial asthma against this small dose, preventing exacerbations.

At the beginning of therapy in adults, the use of no more than two inhalations a day is indicated, and under special conditions, by obligatory agreement with the attending physician, no more than eight inhalations a day. Having determined the really treating dose, you should slowly and gradually try to reduce the number of daily inhalations, reducing them by one. The ideal is one dose once a day, followed by a possible withdrawal of this serious remedy.

This highly active combination medicine is produced by Astrazeneca from Great Britain, and a bottle of powder for inhalation for 120 doses at the rate of 160 micrograms of the hormone and 4.5 mcg of the bronchodilator fenoterol costs from 2000 to 2700 rubles. The drug has analogues, which cost considerably cheaper, in the same dosage and in the same bottle, starting from only 860 rubles.

Advantages and disadvantages

Like any hormonal medication, Symbicort has its disadvantages, particularly its immunosuppressive effect. Quite often its use causes headaches, palpitations and tremors, and due to a decrease in immunity with prolonged use there may be thrush, or candidiasis of the mucous membrane of the mouth and throat. These side effects develop quite frequently, ranging from 1% to 10% of all patients. Also this drug has a rather high cost, but the best quality. During pregnancy, it is best not to use this medicine, but only if the benefits of using the drug would be greater than the possible risk to the unborn child.

Xolar (Omalizumab) is a monoclonal antibody

Popularity Rating:* 4.7

Finally, the crowning feature of modern drug therapy, as with many other diseases (psoriasis, multiple sclerosis), is the expensive treatment with recombinant humanized monoclonal specific antibodies. There is also such a remedy for the treatment of asthma. This drug has a pronounced immunosuppressive effect, and is shown only to patients with an allergic type of bronchial asthma, which is also called atopic. Roughly speaking, Xolar binds to immunoglobulins E and eliminates the flow of allergic reactions mediated by reactants. Free immunoglobulin E becomes scarce, the cascade of allergic reactions is not triggered, and therefore bronchial asthma attacks either do not occur or are much milder.

The drug is indicated for planned treatment of severe allergic bronchial asthma, especially when it is impossible to control the condition with the use of hormonal drugs, i.e. in patients with unpredictable attacks. The second indication is the treatment of severe forms of idiopathic urticaria, which is not treated in any way with anti-allergic agents.

Xolar is administered in subcutaneous injections, it must never be administered intramuscularly or intravenously. The routes of administration and doses are subject to a special calculation, which is not done here. However, it should be said that the drug is injected subcutaneously once a month, or every two weeks, depending on the initial concentration of immunoglobulin E in the blood plasma and depending on the patient’s body weight. So, if a patient has a mass of 80 kg, and the concentration of immunoglobulins E is higher than 400 units per ml, he is prescribed 300 mg of the product subcutaneously after 2 weeks.

On average, the effect of treatment manifested itself after 4 months, and this remedy is recommended for long-term therapy. If it is discontinued, immunoglobulin E rises again, and the severity of bronchial asthma increases again. The effect of its use is less frequent development of attacks, less need for emergency treatment, relief of attacks and improvement of well-being during the inter-ictal period.

It is important to remember that Xolar is not intended to relieve acute attacks, or treat asthmatic status. The advantages and disadvantages, overdose and side effects are deliberately not given here, because the instruction for use of the drug is a multipage book, it must either be studied in great detail or not to use the drug at all.

It remains to report the price of this medication, manufactured by Novartis Pharma. Like all monoclonal antibodies, it requires a very complex technological cycle, and therefore the drug is very, very expensive for Russians. A bottle of lyophilisate for preparation of concentrate in amount of 150 mg will cost on the average 20000 rubles in pharmacies. Accordingly, a dose of 300 mg will cost the patient 40000 rubles, and the monthly cost of treatment will be 80 thousand rubles. If we take into account that Xolar is a remedy for a long-term therapy, then the cost of treatment during a year will amount to 960 thousand rubles, which is equal to the cost of a domestic new off-road car UAZ Patriot.

Spiriva (tiotropium bromide)

Popularity Rating:* 4.6

Finally, to conclude the review of drugs used in severe bronchial asthma, in the fifth stage of treatment, consider the drug Spiriva, or tiotropium bromide. This drug is manufactured by the German company Boehringer Ingelheim, it is available as capsules with powder for inhalation, each capsule contains 18 mcg of tiotropium. Such a pack of 30 capsules, sold together with an inhaler, will retail for 2,200 to 2,700 rubles.

What is this medication? It is recommended as an adjunct to fifth-line therapy for all patients with bronchial asthma, in whom, despite all the proper treatment, it is severe, and patients are already on high doses of inhaled corticosteroids. These patients may also already be receiving monoclonal antibodies, so tiotropium, despite its rather high price, seems economically negligible compared to the previous medication.

What is the product? It is a cholinolytic at muscarinic receptors with long-lasting action. The result of blockade of specific muscarinic receptors will be a marked relaxation of the smooth muscles, or a bronchodilator effect, which is dose-dependent, but lasts at least 24 hours.

Taking this drug increases the spirogram readings as early as half an hour after a single dose, and this effect lasts for a day. Spiriva reduces shortness of breath, exercise tolerance, number of exacerbations, and as a result significantly improves the patient’s quality of life. It is well known that during treatment with this drug, the risk of death was reduced by 16%, which is very high. This drug is shown only as a supportive therapy, and in no case should be used as a means to relieve exacerbation. Spiriva is available for inhaled use, one capsule per day at the same time.

Advantages and disadvantages

Improved quality of life, improved course of the disease, reduced symptoms, and a 16% reduction in overall mortality are excellent data, and the drug is extremely beneficial. But you should still remember that you need to use the inhaler correctly, have specific skills, and an overdose may cause dryness in the mouth and eyes, the development of conjunctivitis. Spiriva should in no case be used at the beginning of treatment, in mild forms of bronchial asthma, and should not be used for emergency therapy of attacks. It should be remembered that the drug should not be used in the first trimester of pregnancy, in children under 18 years of age, and special care should be taken when prescribing Spiriva in patients with glaucoma, prostatic hyperplasia (adenoma) or bladder neck obstruction to avoid difficulty in urination.

*The popularity rating is based on an analysis of demand data from the wordstat service..