Bronchodilators: Short-acting beta2-agonist 'reliever' inhaler (e.g. salbutamol, terbutaline)

Most mild to moderate symptoms of asthma can be relieved rapidly following the administration of an inhaled short-acting beta2-agonist inhaler. This is the first line of treatment for asthma for all ages. With B2 receptor specificity, the myocardial side effects are minimal with this medication. However, the presence of some B2 receptors in myocardial tissue results in tachycardia and palpitations. This is the main dose-limiting factor of this medication.

Long-acting beta2-agonists (e.g. salmeterol, formoterol)

Long-acting beta2-agonists are used as prophylactic therapy and only in conjunction with an inhaled corticosteroid. Salmeterol should not be used to relieve an asthma attack because of its slower onset of action. However, formoterol is the exception to this rule as it is licensed for shortterm relief of symptoms and for the prevention of exerciseinduced bronchospasm. Antimuscarinics Antimuscarinics (e.g. ipratropium) have been shown to be of little value in managing chronic asthma and are regarded as being more effective in relieving bronchoconstriction associated with COPD than for treating asthma. They are not recommended in the treatment pathways, but may be considered if a patient has concurrent COPD.

Corticosteroids

Corticosteroids (e.g. beclometasone) act as a 'preventer' inhaler to reduce inflammation by activating intracellular receptors and inhibiting phospholipase A2, which inhibits the production of prostaglandins and leukotrienes. They should be used on a regular basis to enable their protective effect to build up, and to reduce the risk of exacerbations. Alleviation of symptoms usually occurs three to seven days after initiation. Failure to use these inhalers regularly and confusing them with the 'reliever' inhaler is a common reason for poorly controlled asthma. Side-effects for inhaled corticosteroids remain low at recommended doses.

High doses administered for long periods of time have been associated with adrenal suppression, hence excessive doses should be avoided. Growth restriction in children does not appear to occur at recommended doses, although any child receiving prolonged treatment should be monitored. All patients receiving high doses of steroids should receive a steroid card detailing their treatment.