Those with nocturnal symptoms may respond to evening administration of a long-acting B-agonist or theophylline. If attacks continue to be frequent a trial of an additional anti-inflammatory agent is the next step. An anti-leukotriene or cromolyn or nedocromil may be added. It should be emphasized again that the decision to start or stop medications should be based on objective findings (spirometry or peak flow readings) in addition to the patient's symptoms and frequency of attacks.



Treatment Strategy: Moderate to Severe Asthma

Patients with moderate to severe asthma often need courses of oral corticosteroids when they continue to experience attacks and have lowered flow rates despite maximal first and second-line therapy. It is always helpful before starting oral corticosteroids to review the correct use of MDI sprays as well as to emphasize the use and benefit of a spacer. Discussions between patient and physician must be frequent in this group to reiterate individual goals of treatment and to discuss the potential side effects of oral corticosteroids. Often it will become clear that a medication (usually inhaled corticosteroid) has not been used due to fear of dependency or side effects. When these questions are answered satisfactorily, resumption of this medication may avoid the use of oral steroids and their side effects.

Treatment Strategy: Severe Asthma

In the patient with severe persistent asthma a home nebulizer should be considered. This device may be used to deliver not only a B2-adrenergic agonist but also cromolyn sodium. This combined aerosol therapy may be extremely helpful in certain patients. A nebulizer may not prove more advantageous than medication delivered by MDI for every patient.

Severe Asthma: The Next Step

Patients with severe persistent asthma require high doses of inhaled corticosteroids, long-acting B2-agonist, theophylline, and frequent courses of oral corticosteroid. Maintenance oral steroid may also be necessary. This should always be given in the smallest dose that is effective and only after a trial of alternate day therapy. The addition of an anti-Ieukotriene may permit a reduction in the daily steroid dosage. This reduction must be done carefully with monitoring for the development of adrenal insufficiency. Those patients who need more than 10 mg of prednisone (or its equivalent) with significant side effects such as osteoporosis for maintenance should be considered candidates for trials of steroid sparing anti-inflammatory agents such as methotrexate. Discussion of potential reactions and success rates of these agents must take place before initiating this third-line therapy.