The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations in the emergency department is not discussed here.

View the Comparison Chart: Some Inhaled Drugs for Treatment of Asthma

The FDA has approved Airsupra (AstraZeneca), a metered-dose inhaler containing the short-acting beta₂-agonist (SABA) albuterol and the inhaled corticosteroid (ICS) budesonide, for use as needed for treatment or prevention of bronchoconstriction and to reduce the risk of exacerbations in patients ≥18 years old with asthma. Airsupra is the first combination of a SABA and an ICS to become available in the US. It is not approved for use as maintenance therapy.

The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations of asthma in the emergency department is not discussed here.

View the table: Some Inhaled Drugs for Treatment of Asthma

The main goals of treatment for chronic obstructive pulmonary disease (COPD) are to relieve symptoms, reduce the frequency and severity of exacerbations, and prevent disease progression. Several guidelines and review articles on COPD treatment have been published in recent years. Treatment of acute exacerbations is not discussed here.

View the Comparison Table: Inhaled Long-Acting Bronchodilators for Treatment of COPD

View the Comparison Table: Inhaled Corticosteroids for Treatment of COPD

The FDA has approved Trelegy Ellipta (GSK), a fixed-dose combination of the inhaled corticosteroid (ICS) fluticasone furoate, the long-acting antimuscarinic agent (LAMA) umeclidinium, and the long-acting beta₂-agonist (LABA) vilanterol. It is available as a dry powder inhaler for once-daily maintenance treatment of COPD and to reduce COPD exacerbations in patients with a history of exacerbations. Trelegy Ellipta is the first three-drug inhaler for treatment of COPD to become available in the US.

The goal of asthma treatment is to control symptoms and prevent exacerbations. Management of acute exacerbations of asthma is not discussed here.

View the Comparison Table: Some Inhaled Drugs for Treatment of Asthma

View the Comparison Table: Correct Use of Inhalers

The main goals of treatment for chronic obstructive pulmonary disease (COPD) are to relieve symptoms, reduce the frequency and severity of exacerbations, and prevent disease progression. Updated guidelines for treatment of COPD have been published in recent years.

View the Comparison Table: Some Inhaled Corticosteroids for COPD

View the Table: Correct Use of Inhalers for COPD

The FDA has approved Arnuity Ellipta (GSK), a single-agent inhaler containing the corticosteroid fluticasone furoate, for once-daily maintenance treatment of asthma in patients ≥12 years old. Fluticasone furoate is also available in combination with the long-acting beta₂-agonist vilanterol as Breo Ellipta for treatment of asthma and COPD.

Olodaterol (Striverdi Respimat – Boehringer Ingelheim), a new inhaled long-acting beta₂-agonist, has been approved by the FDA for once-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD). It is not approved for treatment of acute exacerbations of COPD or for treatment of asthma. Olodaterol is the third long-acting beta₂-agonist to be approved by the FDA for once-daily use; indacaterol (Arcapta Neohaler), which is available as a single agent, and vilanterol, which is available only in fixed-dose combinations with the long-acting anticholinergic umeclidinium (Anoro Ellipta) or the corticosteroid fluticasone furoate (Breo Ellipta), were approved earlier.

The FDA has approved an inhaled fixed-dose combination of the long-acting anticholinergic umeclidinium (ue mek" li din' ee um) and the long-acting beta₂-adrenergic agonist (LABA) vilanterol (Anoro Ellipta – GSK/Theravance) for once-daily maintenance treatment of chronic obstructive pulmonary disease (COPD). Anoro Ellipta is the first product available in the US that combines two long-acting bronchodilators in a single delivery device.

The FDA has approved an inhaled fixed-dose combination (Breo Ellipta – GSK/Theravance) of the corticosteroid fluticasone furoate and the long-acting beta₂-adrenergic agonist (LABA) vilanterol trifenatate for once-daily treatment of chronic obstructive pulmonary disease (COPD).

INHALATION DEVICES — Metered-dose inhalers (MDIs) require coordination of inhalation with hand-actuation of the device. Valved holding chambers (VHCs) or spacers help some patients, especially young children and the elderly, use MDIs effectively. VHCs have one-way valves that prevent the patient from exhaling into the device, minimizing the need for coordinated actuation and inhalation. Spacers are tubes or chambers placed between the canister and a face mask or mouthpiece, which also avoids the need to coordinate actuation and inhalation. Both VHCs and spacers retain the larger particles emitted from the MDI, decreasing their deposition in the oropharynx and leading to a higher proportion of small respirable particles being inhaled.

The FDA has approved aclidinium bromide (Tudorza Pressair – Forest), an orally-inhaled long-acting anticholinergic, for long-term maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD).

The FDA has approved indacaterol (in´´ da ka´ ter ol; Arcapta Neohaler – Novartis), an inhaled long-acting beta₂-agonist, for once-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD). Indacaterol is not approved for treatment of exacerbations of COPD or for treatment of asthma. It has been available in Europe as Onbrez Breezhaler since 2009.

Inhalation is the preferred route of delivery for most asthma drugs. Chlorofluorocarbons (CFCs), which have ozone-depleting properties, are being phased out as propellants in metered-dose inhalers. Non-chlorinated hydrofluoroalkane (HFA) propellants, which do not deplete the ozone layer, are being used instead.

The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and decrease complications of the disease such as acute exacerbations. Other guidelines for treatment of this condition have been published or updated in recent years.

A little more than a year ago, The Medical Letter reported the results of an FDA meta-analysis which found that use of a long-acting beta-2 agonist (LABA) such as salmeterol (Severent) or formoterol (Foradil) in patients with asthma was associated with an increased risk of a composite endpoint of asthma-related death, intubation or hospitalization; the highest risk was in children 4-11 years old.There was no significant increase in risk when a long-acting beta-2 agonist was used with an inhaled corticosteroid.The Medical Letter recommended that long-acting beta-2 agonists should not be used as monotherapy for asthma, especially in children, and that long-acting beta-2 agonists should be used for asthma only in combination with an inhaled corticosteroid, preferably in a fixed-dose combination in the same inhaler.1

Now the FDA has issued new Safe Use Requirements2 and labeling requirements for long-acting beta-2 agonists that include the following: “Stop use of the LABA, if possible, once asthma control is achieved and maintain the use of an asthma-controller medication such as an inhaled corticosteroid.”3

It has not been determined that patients taking a longacting beta-2 agonist in a fixed-dose combination with an inhaled corticosteroid have an increased risk of death or that stopping long-acting beta-2 agonists in such patients will improve long-term outcomes. A controlled clinical trial of these new requirements would be welcome.

1. Long-acting beta-2 agonists in asthma. Med Lett Drugs Ther 2009; 51:1.
2. www.fda.gov/safety/medwatch/default.htm
3. BA Chowdhury and G Dal Pan. The FDA and safe use of long-acting beta-agonists in the treatment of asthma. N Engl J Med 2010; Feb 24 (epub).

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No truly new drugs have been approved for treatment of asthma since omalizumab (Xolair) in 2003, but some randomized controlled trials of older drugs have been published, and new guidelines have become available.

A combination of the corticosteroid budesonide and the long-acting beta₂-agonist formoterol (Symbicort - AstraZeneca) has become available in a metered dose inhaler for long-term maintenance treatment of asthma in patients ≥ 12 years old. A combination product that contains fluticasone propionate and salmeterol (Advair) is already available for this indication in the US. Neither one of these combinations is approved for acute treatment of asthma symptoms. A dry powder inhaler formulation of Symbicort has been available in Europe and Canada for several years.

Formoterol fumarate (Perforomist - Dey), a long-acting beta₂-agonist, was recently approved by the FDA as an inhalation solution for nebulization for maintenance treatment of bronchoconstriction associated with chronic obstructive pulmonary disease (COPD). Arformoterol (Brovana), the (R, R)-enantiomer of formoterol, was approved earlier this year for the same indication.

The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and minimize complications of the disease such as acute exacerbations and cor pulmonale. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines developed by the World Health Organization and the National Heart, Lung and Blood Institute were updated in 2006. The American Thoracic Society and the European Respiratory Society jointly developed guidelines for COPD in 2004.

Patients with mild, infrequent asthma symptoms may require only intermittent, asneeded use of an inhaled short-acting beta2-adrenergic agonist. Use of a short-acting beta2-agonist more than twice weekly, other than for exercise-induced bronchospasm, indicates a need for anti-inflammatory treatment. Inhaled corticosteroids are the most effective anti-inflammatory medication; leukotriene modifiers are less effective alternatives. If regular use of an inhaled corticosteroid in a low dose does not prevent symptoms, a long-acting beta2-agonist should be added; addition of a second drug is more effective than raising the dose of the inhaled steroid. A leukotriene modifier can also be used as the second drug. Omalizumab may be considered as adjunctive therapy for patients more than 12 years old who have allergic asthma not controlled by other drugs. A short course of oral corticosteroids may be useful for acute exacerbations. Treatment of acute severe asthma as a medical emergency is not included here; it has been reviewed elsewhere (ER McFadden Jr, Am J Respir Crit Care Med 2003; 168:740).

New drug formulations continue to be introduced for the treatment of asthma, and new studies on older drugs continue to change our perspectives on the management of this chronic inflammatory disease. Treatment of asthma in the emergency department or hospital is not addressed here. More information on the diagnosis and treatment of asthma is available from Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda:NIH, 1997 and 2002 update; www.nhlbi.nih.gov).