Asthma should always be regarded as a twenty-four-hour illness and treatment should not be directed solely at the nighttime hours. Choosing Medication for Nocturnal Asthma Many medications may be used to treat nocturnal asthma. More than one agent may be needed for patients with severe and frequent attacks. B2-agonists are available in long-acting forms both in aerosol (salmeterol) and tablet form (albuterol) that may be administered at night. By improving lung function and preventing nocturnal attacks, these agents may actually improve quality of sleep. Theophylline in sustained-release forms allows once-or twice-a-day dosing and is suitable for nocturnal asthma treatment. The physician can time administration of this medication so peak blood levels are obtained during sleep. A common approach is one sustained release preparation after the evening meal. Remember, theophylline blood levels can be measured and each sustained preparation is unique. One drawback of theophylline for nocturnal asthma is its potentially adverse effect of insomnia. Patients who limit their caffeine intake may reduce this effect. Because overactivity of the cholinergic nervous system has been implicated in nocturnal asthma, anticholingeric agents have been administered at bedtime in patients with nocturnal asthma. High doses (ten puffs) of ipratropium bromide have been administered with conflicting results in several studies. At this time it does not appear that this agent is more effective than long-acting B2-agonists for treating nocturnal asthma. Patients with moderate to severe nocturnal asthma may need oral corticosteroids to control their symptoms. Studies of the timing of administration of this medication have shown dosing in early morning or evening does not achieve better control of nocturnal asthma. In these studies, patients who took steroid dosages at three P.M., however, significantly reduced the likelihood of nocturnal attacks. Patients who continue to suffer nocturnal attacks despite aggressive therapy may need to awaken one hour before their usual night time attack to administer a short acting B2-agonist, an approach termed "therapeutic awakening."