Medicines An important management tool

Medication plays a very important role in the day-to-day management of asthma. Make sure that you are well-organised when it comes to your medication. Always take it as prescribed, and ensure that you never run out.
This section of our website can help you learn how and why they work. Then you will understand why it is so important to follow the rules about taking medication. Here we discuss 5 types of medication :
Preventer medication is probably your most important asthma medication, because it treats the inflammation inside your airways, and reduces the likelihood of an asthma exacerbation.
Reliever medication brings short term relief from asthma by relaxing the tight bands of muscle around your airways. This helps air flow in and out of your lungs more freely.
Symptom controllers are taken twice a day to keep the muscle relaxed, and last 12 hours. They don’t have the same effect as the preventer inhalers, and a preventer is always prescribed at the same time.
Combination inhalers contain both preventer and symptom controller medicine in one device. Combination inhalers should not be used in emergency situations.
Prednisone is used in severe episodes of asthma. It works slowly over several hours to reverse the swelling of the airways.

Preventer Medication – Your most important asthma medication

When you have asthma, your airway walls become leaky, and harmful triggers can get through and cause swelling. Preventer medicines help to seal up your airway walls. This helps break the cycle of swelling and mucus production, and makes room for air to flow freely.
Preventer medicines work slowly and it may take you up to three months of regular use (generally twice a day) to notice the full benefit of the medicine. It can be dangerous to skip a few doses or stop your preventer when you feel well, as your asthma will often get worse.
Preventer inhalers are usually brown, orange or dark red. Examples of preventer medicines are Beclazone, Flixotide, Respocort, Vicrom and Pulmicort.

Corticosteroid Preventers

Most preventer medicines are steroids, which mimic the steroid we produce naturally in our bodies every day. An enormous body of research demonstrates that they are safe and effective for long term use.
Like all drugs, there can be side effects, which are less common in moderate doses. Side effects may include a husky voice, a sore throat or fungal growth in the mouth (thrush). The risk of side effects can usually be easily minimised by:

• using a spacer (for people who use a Metered Dose Inhaler (MDI)); and
• rinsing the mouth after inhaler use

More general side effects occur infrequently. These are due to tiny amounts of the drug being absorbed into the blood stream. The liver will clean up most of this but if very high doses of inhaled steroids are used there may be some side effects which include:

• thinning of the bones called osteoporosis
• thinning of the skin giving rise to easy bruising
• a reduction in the body’s ability to respond to a severe medical illness.

For children, an additional problem can be minor growth suppression. This is unlikely when moderate doses are used.
Most experts agree that the risk of poorly treated asthma is far greater than the risk of serious side effect from inhaled corticosteroids. Anyone who is concerned about possible side effects from their medication should discuss the matter with their doctor.

Non-steroidal Preventers

Non-steroidal preventer medicines can be useful in mild asthma, especially in children. An extra dose can be taken before exercise if needed to prevent cough and wheeze. They are free of most side effects, apart from throat irritation. Examples are: Intal and Vicrom.

Can I reduce my medication dosage?

If you have been well for 3-6 months, your doctor may suggest you try this as part of your Self Management Plan. It is always best to keep a small supply of your asthma medicine, just in case something triggers your asthma.

Reliever medication

Reliever medicine brings short term relief from asthma by relaxing the tight bands of muscle around your airways. This helps air flow in and out of your lungs more freely.
Relievers can help wheezing, coughing or tightness in the chest. They are only taken when you need them. Many people rely on their reliever inhaler to feel better immediately, but they do not treat the underlying cause of their asthma (swollen and inflamed airways) by regularly using their preventer. Relievers don’t have a lasting effect like preventers – their effect wears off in a few hours and they don’t change the swelling in the breathing tube.
Reliever inhalers are usually blue. Examples of reliever medicine are Bricanyl, Salamol and Ventolin. Some side effects of reliever medicines include mild shaking, headaches, a racing heart, and restlessness.
The medicine Atrovent is also a reliever, although it relaxes the airway muscle in a different way. It is slower to take effect, however it may give longer relief. It is fairly free of side effects, although it may leave a bitter taste and cause some dryness of the mouth.
Some relievers are available in tablet form, and are used for children who can’t manage inhalers and spacers or when inhaled treatment does not seem to work. Side effects are more likely than in inhaled medicine, because the medicine is affecting more parts of the body and the dose is higher. Side effects might include a fast heartbeat, tremor, headache, and hyperactivity.
Examples include: Bambec, Singluair, Volmax, Bricanyl.

Is your asthma under control?

See a doctor or asthma nurse as soon as possible if:

• you take your reliever more than 3-4 times per week, or
• you wake at night or early morning with asthma symptoms, or
• asthma symptoms impact on your daily activities.

Symptom controllers

Long-acting inhaled relievers

Symptom controllers are long acting inhaled relievers that are taken twice a day to keep the muscle relaxed, and last 12 hours. They don’t have the same effect as the preventer inhalers, and a preventer is always prescribed at the same time.
Symptom controllers are likely to help those who wake with symptoms at night and those who have bad asthma with exercise. The need to use a reliever should decrease when a symptom controller is prescribed. Symptom controllers should not be used for immediate or emergency relief, a reliever should still be used in these circumstances.
Examples of symptom controller medication are Foradil, Oxis and Serevent.

Combination Inhalers - The two in one approach

Combination inhalers contain both preventer and symptom controller medicine in one device. They should be taken regularly as prescribed.
Symptom controllers should not be used for immediate or emergency relief, a reliever should still be used in these circumstances.
Examples of combination inhalers are Seretide and Symbicort.

Prednisone

Prednisone medicine is used in severe episodes of asthma. It works slowly over several hours to reverse the swelling of the airways. Prednisone needs to be continued for several days after your asthma symptoms settle to make sure that the swelling doesn’t return. Your doctor may use your peak flow record and symptom diary as a guide to reduce and stop the Prednisone tablets. If you stop too early your asthma may get worse again.
A short course of Prednisone is safe with no lasting side effects. If you need Prednisone tablets more than twice a year, your asthma is not under control. Talk to your doctor about your options. You may need to review your Self Management Plan or visit a specialist.

The tablets and doses used

The tablet most commonly used is Prednisone, which comes in sizes of 1mg, 5mg, and 20mg. Others less often used are Betnesol (0.5mg soluble tablet), Cortisone (5 & 25mg), Dexamethasone (1 & 4mg), Medrol (4mg), and Prednisolone (very similar to Prednisone).
The dose varies such a lot depending on the person – from 2-3mg to 40mg per day. The doctor will all the time be attempting to bring the dose down to the lowest possible in order to reduce the likelihood of side effects.

Long term Prednisone use

Many people are accustomed to taking short courses (a few days or weeks) of steroid tablets (usually Prednisone) for attacks of asthma. However some people have asthma that causes problems all the time, despite looking after themselves well and using their inhalers properly. These people may need to use steroid tablets continuously (every day or on alternate days) to control their asthma.
A respiratory specialist should first be seen to check that all other possible treatments have been explored, before someone engages on long term steroid treatment.

Side effects

When steroid tablets are taken in short bursts (under about three weeks), there are usually no problems. There can be increased appetite, mood change (a high mood more often than a depressed one), and occasionally fluid retention and indigestion.
Unwanted side effects happen the longer you take the steroid and the higher the dose used. The main ones are:

• Increased appetite and weight gain.
• Thinning of the bones, which can lead to bone fractures if very severe.
• Slowing of growth in children.
• The body’s own natural production of the steroid cortisol is reduced; this can be a problem when steroid tablets are stopped or when the body needs a surge of more steroid to cope with an acute illness.
• Easy bruising of the skin and slow healing of cuts.
• Puffiness or roundness of the face.
• Indigestion or stomach ulcers.
• Fluid retention with swelling of the ankles.
• Cataracts in the eyes.

Doses of Prednisone below 7mg a day are unlikely to give problems other than possible skin thinning. 10mg/day or more will most likely give some of these effects after a few years. The higher the dose the more likely side effects are, so the doctor will be weighing up the risks of poor asthma control against the risk of steroid side effects and will keep the dose as low as possible.

You can help keep the dose down by:

• taking your other asthma medicines as usual;
• using your inhaler right – ask someone to check you or see if an alternative device or a spacer could be of help;
• measuring your peak flow every day, and follow a Self Management Plan, starting extra treatment early;
• letting the doctor know if your peak flow reading drops or you feel unwell.

Good timing

The timing and frequency of taking the tablets can also influence side effects. Fewer side effects occur if:

• the steroid tablets can be taken every other day, instead of each day (even if a slightly bigger dose is needed to keep the asthma under control);
• the daily dose is taken as a single dose in the morning. Morning is the time the body normally products its cortisone for the day;
• take during or after meals.

Weight control

You put on weight when energy taken into the body (in food and drink) is greater than the energy the body uses (in exercise). Aim to keep your weight down by keeping to sensible eating habits.

• Eat three meals daily.
• Include foods that are high in fibre – for example wholegrain breads and cereals, vegetables and fruits.
• Eat a wide variety of foods, for daily vitamin and mineral requirements.
• Avoid foods containing large amounts of fats – especially takeaways and fried foods.
• Avoid foods such as cakes, biscuits and soft drinks.
• Drink plenty of fluids such as water, tea and coffee, and avoid alcohol which is full of calories.
• Weigh yourself regularly and if you keep putting on weight, as for extra help.

Bone strength

Long-term steroid tablet treatment can weaken bones. This can’t be prevented altogether, but can be reduced if:

• you stay as fit and active as possible;
• you are able to take a low dose of calcium tablets. Your doctor will decide this. It can be harmful, particularly in people with kidney disease. If calcium treatment is given, regular blood tests will be done to look for side effects from the calcium.
• There are now some other medications that can keep the bones stronger; your doctor can discuss this with you or refer you to a specialist in the bone field. a special sort of x-ray may be needed to measure the density of the bone (it is quite easy and doesn’t hurt) before deciding on the best treatment to use and even whether treatment is needed at all.

Extra steroid doses

Because the body’s own natural steroid production is switched off when you take steroid tablets for a long time, it may not be able to respond quickly enough if suddenly your body needs an extra boost of steroid. So you will need to take extra doses of the steroid tablet instead. This can happen during illnesses.
If you are taking long-term steroid treatment you may need extra steroid during illnesses such as bad ‘flu, operations, asthma attacks and dental work or during any important health problem. See your doctor straight away if you become ill.
Your doctor may be able to help you plan ahead for certain problems. As a guide, you may need an extra 5-10mg of Prednisone each day for a bad ‘flu which has not affected your asthma.
If you are vomiting or unable to swallow tablets, contact your doctor urgently. You must not be without steroid medicine, particularly if you are unwell.

Stopping long-term steroid treatment

For the same reason, it can be quite dangerous to stop long-term treatment suddenly – the body can find itself seriously short of steroid.
Anyone taking regular steroid tablets should wear a Medic-Alert bracelet. Then, if an accident occurs, and extra steroid is needed, the doctors will know.
When long-term treatment is to be stopped, this must be done very gradually. The dose must be slowly reduced, often over several months. This allows the body time to start making its own cortisone again, Slow reduction will also stop unpleasant side effects, such as severe muscle aches, arthritis and depression.
Slow reduction of steroid treatment must be done by your doctor, and the asthma carefully watched so it doesn’t worsen.
Points to remember

• Long-term treatment with steroid tablets is only needed in a small number of people with asthma.
• Good asthma care will reduce the need for steroid tablets.
• If you need steroid tablets your doctor must supervise this treatment. You should see him or her regularly.
• Side effects can be reduced by taking steroid tablets:
• as a single dose in the morning;
• every other morning (if this is possible).
• A Medic-alert bracelet for steroids is only need by people taking steroid tablets for months or years.
• It is dangerous to stop steroid tablets suddenly if they have been taken continuously for months or years.
• The Asthma Foundation recommends that everyone with a respiratory condition sees a health professional about a free flu vaccination.