Asthma is a lung condition, whereby the airways become inflamed and swollen. There is no cure, so management is focused on relieving symptoms. Inhaled bronchodilators are commonly used (both short- and long-acting), as are inhaled corticosteroids. Other drugs that may be used include leukotriene receptor antagonists (montelukast, zafirlukast), methylxanthines (theophylline), cromoglicate, nedocromil, oral beta2 agonists (bambuterol, albutamol, terbutaline), oral corticosteroids (prednisolone).

Dosage regimen

* Inhaled short-acting beta₂ agonists (salbutamol, terbutaline) are taken when required.

* Inhaled long-acting beta₂ agonists (salmeterol, formeterol) - also known as LABA - are taken twice a day.

* Inhaled short-acting anticholinergics (ipratropium) are taken three or four times a day.

* Inhaled corticosteroids (beclometasone, budesonide, fluticasone, mometasone) are usually taken twice a day. The exception is ciclosonide, which is usually taken once daily.

* Sodium cromoglicate is usually taken four times a day. Additional doses may be taken before exercise.

* Methylxanthines (theophylline) are taken every 12 hours.

* Nedocromil is usually used four times a day, but this can be reduced to twice daily.

* The leukotriene receptor antagonist montelukast is taken in the evening, whereas zafirlukast is usually taken twice daily.

* Oral beta₂ agonists are usually reserved for use at night.

* Oral corticosteroids are usually reserved for infections or worsening asthma, but patients may have a short course of high dose prednisolone for such a scenario and shold know how and when to use them.

Patient's knowledge of the medicine's use

* Beta₂ agonists reduce breathlessness, and asthma symptoms respond rapidly to such treatment. Short-acting agents may be used when required, but if needed more than once daily, prophylaxis (or a review of existing prophylaxis) should be initiated. Long-acting beta₂ agonists are used prophylactically for chronic asthma, and patients should be advised that such agents will be ineffective in at relieving acute exacerbations. Oral beta₂ agonists may be used at night where nocturnal asthma is an issue.

* Anticholinergics reduce breathlessness, bronchoconstriction and mucus secretion, but short-acting beta₂ agonists are more effective and are usually preferred.

* Corticosteroids have an anti-inflammatory effect. A patient who used an inhaled corticosteroid for three to four weeks and experiences an improvement in symptoms is likely to have asthma, rather than COPD. They should be used rehgularly to achieve maximum benefit.

* Methylxanthines also have an anti-inflammatory effect. They may be used by patients who cannot use inhalers byut requiring long-term treatment, or added to inhaled therapy where symptoms are not receding sufficiently.

* Cromoglicate and nedocromil may be used for patients who have allergy-associated asthma. Their mechanism of action is unclear.

* Leukotriene receptor antagonists are used in patients who suffer from exercise-induced asthma, or may be added to inhaled corticosteroids where an additive effect is required.

Is the medicine working?

* Asking the following questions will show how effective drug treatment is, and the impact the condition has on the patient's life:

• Has your breathing improved?

   

• How often do you experience shortness of breath and/or use your reliever medication?

   

• Does your asthma affect your social or family life?

   

• Do you sleep well at night?

   

* Ensure the patient is using their inhaler, and spacer device if applicable, correctly. A review of technique may be helpful.

Side effects

* Beta2 agonists commonly cause cramp, tachycardia, nervousness and tremor.

* Anticholinergics commonly cause a cough and a dry mouth.

* Methylxanthines commonly cause gastrointestinal reflux, headache and nausea.

* Corticosteroids can cause adrenal suppression (ensure the patient has a steroid card) and glaucoma. If the patient experiences hoarseness or candidiasis, advice them to rinse the mouth with water after use or to use a spacer.

* Cromoglicate and nedocromil commonly cause throat irritation, transient bronchospasm, and cough.

* Leukotriene receptor antagonists commonly causes thirst, abdominal pain and a headache.

Monitoring

* Beta₂ agonists can cause severe hypokalaemia. Therefore plasma levels should be regularly checked.

* Theopylline has a narrow therapeutic index. Make sure the patient can recognise the signs of toxicity (convulsions and arrhythmias). Advice them to contact their doctor immediately if this happens.

* If patients taking corticosteroids develop paradoxical bronchospasm they should immediately stop taking the drug and contact their doctor.

* Ensure the patient knows what an asthma attack is likely to feel like, and the appropriate course of action.

Lifestyle

* Encourage patient to be more physically active as this can improve exercise tolerance.

* Patients should avoid royal jelly products as this can trigger an attack.

* Encourage asthma sufferers to eat more fruit and vegetables as these help build up the immune system.

* Stress can cause an attack: advise the patient to try relaxation techniques such as yoga, and meditation.

* The patient should be encouraged to stop smoking.

* Asthma can be triggered by certain allergens. Encourage the patient to try and identify any that affect them (for example, animal dander, pollen, fungal spores) and avoid them if possible.

Uzma Chaudhry, Relief Pharmacist, Lloyds Pharmacy, Oxfordshire

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