Asthma - Treatment

Reliever inhalers

Reliever inhalers, which are usually blue, are taken when needed to relieve asthma symptoms quickly.

They normally contain a medicine called a short-acting beta2-agonist, which widens the airways and makes breathing easier. They typically work for no more than 15 minutes or so.

Everyone with asthma should have a reliever inhaler, although you ideally shouldn't need to use it very often. You may not need it at all if you are using a regular preventer inhaler (see below).

Speak to your GP or asthma nurse if you need to use it three or more times a week, as this means a preventer inhaler (see below) may be needed.

Reliever inhalers are generally very safe medicines and have few side effects as long as they're not used too much.

After using the inhaler, some people may experience:

• mild shaking of the hands (tremors)
• headaches
• muscle cramps
• a fast, pounding or fluttering heartbeat (palpitations)

These side effects aren't dangerous and should pass within a few minutes.

Want to know more?

• Asthma UK: reliever inhalers

Preventer inhalers

Preventer inhalers, which are usually brown or orange, are used twice or occasionally once a day to stop asthma symptoms occurring.

They contain inhaled steroid medication, which works by reducing the inflammation (swelling) and sensitivity of the airways.

Preventer inhalers are usually recommended if you have asthma symptoms more than twice a week. It's important to use them regularly even if you don't have symptoms, because they keep the inflammation in the breathing tubes under control, and this can get worse again if you stop using your inhaler.

Preventer inhalers don't work straight away, so you'll need to keep using your reliever inhaler to begin with. You may also need to use your reliever inhaler if you do experience any occasional symptoms.

Speak to your GP or asthma nurse if you continue to have frequent symptoms while using a preventer inhaler.

Preventer inhalers are very safe at usual doses, but they can cause side effects at high doses, especially with long-term use.

Possible side effects include:

• a fungal infection of the mouth or throat (oral thrush)
• a hoarse voice
• a sore throat

Using a spacer (see How to use your inhaler below) can help prevent these side effects, as can rinsing your mouth or cleaning your teeth after using your inhaler.

Want to know more?

• Asthma UK: preventer inhalers

Other treatments

If your symptoms aren't well controlled with reliever and preventer inhalers, you may need one or more of the treatments below.

Long-acting reliever inhalers

Long-acting reliever inhalers work in the same way as normal reliever inhalers, but their effects can last for up to 12 hours so they can be used less often.

They usually contain a medicine called a long-acting reliever (long-acting bronchodilator/long-acting beta2-agonist).

Long-acting reliever inhalers are always used alongside preventer inhalers, often in a single combined inhaler. This can allow your preventer dose to be lowered, while still keeping your symptoms under control.

Combination inhalers are usually purple, maroon or red.

Long-acting relievers can cause similar side effects to short-acting relievers, such as temporary shaking or cramps.

It's important never to take a long-acting reliever on its own without a preventer. This may temporarily relieve your symptoms, while allowing the inflammation in the breathing tubes to build up, which could result in a sudden severe asthma attack.

Tablets

If you still have symptoms despite using a preventer inhaler and a long-acting reliever inhaler, your doctor may suggest taking tablets to control your symptoms.

The main tablets used for asthma are:

• leukotriene receptor antagonists – taken once a day to stop the airways becoming inflamed (syrup and powder forms are also available)
• theophyllines – taken twice a day to help widen the airways
• steroid tablets – see below

Leukotriene receptor agonists can cause tummy (abdominal) pain and headaches. Side effects of theophylline tablets include nausea, vomiting, tremors and palpitations.

Different people require different doses of theophylline for it to work best. Your GP will periodically measure the level of medication in your blood to check it's not too high or too low. If it's too low, the medication may not work, and if it's too high, side effects are more likely.

Steroid tablets

If your asthma is still not under control, an asthma specialist may prescribe regular steroid tablets.

Steroids are powerful medicines that can reduce inflammation in the airways. They can be used in two ways:

• as an immediate, short-term treatment if you have occasional severe asthma attacks
• as a long-term treatment if other medications don't control your symptoms well enough

Long-term or frequent use of steroid tablets can cause side effects, such as:

• osteoporosis (fragile bones)  
• high blood pressure 
• diabetes 
• increased appetite, leading to weight gain
• cataracts and glaucoma  
• thinning of the skin  
• easy bruising  
• muscle weakness, especially around the thighs and shoulders
• mood changes

With the exception of increased appetite, which is a very common side effect, most of these unwanted effects are uncommon.

You'll be monitored regularly while taking steroid tablets to check for signs of any problems.

Omalizumab (Xolair)

Omalizumab (brand name Xolair), is a new type of medication that can sometimes help prevent frequent, severe asthma attacks that are triggered by allergies. It's less effective at relieving persistent symptoms.

The National Institute for Heath and Care Excellence (NICE) recommends that omalizumab can be used in people over six years of age with allergy-related asthma who need continuous or frequent treatment with steroid tablets.

It's only available on prescription from an asthma specialist and isn't suitable for everyone with asthma.

It's given as an injection every two to four weeks. If your symptoms aren't under control within 16 weeks, treatment should be stopped. It may be continued indefinitely if it does help.

Side effects of omalizumab can include temporary pain, swelling, redness and itching where the injection is given.

Mepolizumab (Nucala)

Mepolizumab (brand name Nucala) is a new type of medicine that can help control severe asthma in some people.

NICE recommends it for some adults who have severe, difficult to control asthma that's associated with a high number of eosinophils in the blood.

Eosinophils are white blood cells that cause the breathing tubes that carry air in and out of the lungs to become swollen and sensitive in some people with asthma.

Mepolizumab reduces the number of these cells in the blood, which may reduce the number of bad asthma attacks you have and/or mean your dose of steroid tablets can be reduced or stopped.

It's given by injection once every four weeks. If it doesn't help after a year, the treatment will be stopped. If it does help, it can be used as a long-term treatment.

Common side effects of mepolizumab include headaches, back pain, and pain, redness and/or swelling where the injection is given.

Want to know more?

• Asthma UK: other medicines and treatments
• Asthma UK: steroid tablets
• NICE: omalizumab for severe persistent allergic asthma
• NICE: mepolizumab for treating severe refractory eosinophilic asthma

Bronchial thermoplasty procedure

Bronchial thermoplasty is a procedure that is very occasionally used as a treatment for severe asthma.

It involves damaging some of the muscles surrounding the airways, which can help stop them becoming narrow.

The procedure is carried out either with sedation (where you're awake but take medication to help you relax) or under general anaesthetic (where you're asleep).

A bronchoscope (a long, flexible tube) is passed down to your lungs through your mouth or nose. Heat is then used to damage the muscles around the airways.

Three treatment sessions are usually needed, with at least three weeks between each session.

There's some evidence to suggest this procedure may reduce asthma attacks and improve the quality of life of someone with severe asthma.

But the long-term risks and benefits are not yet fully understood. There's a small risk it could trigger an asthma attack and cause other complications.

Make sure you discuss this procedure fully with your doctor or surgeon if it's offered.

Want to know more?

• Asthma UK: bronchial thermoplasty
• NICE: bronchial thermoplasty for severe asthma

How to use your inhaler

Not using inhalers correctly and/or forgetting to take asthma medication regularly are the main reasons people with asthma struggle to control their symptoms.

Your doctor or asthma nurse will show you how to use your inhaler properly, or how to help your child use theirs.

Types of inhaler

There are several different inhalers available, which are used in slightly different ways.

The two main types are:

• pressurised canisters – you press the inhaler while breathing in and it releases a spray of medicine into your lungs (these are sometimes used with a device called a spacer –  see below)
• dry powder inhalers – non-pressurised devices that release powdered medication when you breathe in quickly and forcefully

Pressurised containers can be used by most people with asthma. Dry powder inhalers may not be suitable for people who find it difficult to inhale sharply and forcefully, such as young children, the frail and elderly, and those with persistent breathing difficulties. 

It's important to ensure that you use your inhaler correctly, as this will make it easier to control your symptoms and will reduce the risk of any side effects.

Spacers

Pressurised canister inhalers can work better if used with a spacer – a hollow plastic tube or container with a mouthpiece at one end and a hole for the inhaler at the other.

When using a spacer, the spray from the inhaler is released into the container, where it's held while you breathe in very slowly until your lungs are full. You then hold your breath for a few seconds so the medicine settles in your lungs.

Benefits of spacers include:

• they can make inhalers more effective because more of the medicine reaches the lungs
• less medicine stays in the mouth or is swallowed, so problems such as oral thrush are less likely to occur
• they're easier to use for children who may otherwise find it difficult to use an inhaler correctly
• a face mask can be attached to the mouthpiece to make it easier for very young children to breathe in the medicine

Spacers are usually recommended for children with asthma, but they should ideally be used by everyone who uses a preventer spray inhaler, especially if they need to take high doses.

Want to know more?

• Asthma UK: using your inhalers
• Asthma UK: spacers
• Asthma UK: help your child use their inhaler

Work-related asthma

If it's possible you have asthma associated with your job, known as occupational asthma, you'll be referred to an asthma specialist to confirm the diagnosis.

If your employer has an occupational health service, they should also be informed, along with your health and safety officer.

Your employer has a responsibility to protect you from the causes of occupational asthma. It may sometimes be possible to:

• substitute or remove the substance that's triggering your asthma from your workplace
• redeploy you to another role within the company
• provide you with protective breathing equipment

But you may need to consider changing your job or relocating away from your work. It's best to do this within 12 months of your symptoms developing if possible, to reduce the risk of your asthma becoming a long-term problem.

Some people with occupational asthma may be entitled to Industrial Injuries Disablement Benefit.

Want to know more?

• Asthma UK: occupational asthma
• Health and Safety Executive: asthma at work
• GOV.UK: Industrial Injuries Disablement Benefit

Complementary therapies

A number of complementary therapies have been suggested as possible treatments for asthma, including:

• breathing exercises – including techniques called the Papworth method and the Buteyko method
• traditional Chinese herbal medicine
• acupuncture
• ionisers – devices that use an electric current to charge molecules of air
• manual therapies – such as chiropractic
• hypnosis
• homoeopathy
• dietary supplements

However, there's little evidence that any of these treatments, other than breathing exercises, are effective.

There is some evidence that breathing exercises can improve symptoms and reduce the need for reliever medicines in some people, although they shouldn't be used instead of your medicine.

Want to know more?

• Asthma UK: complementary therapies