How do inhaled corticosteroids compare in treating asthma?

There are no differences between inhaled corticosteroids (ICSs) in terms of controlling asthma symptoms, preventing exacerbations, or reducing the need for additional rescue medication (when ICSs are given in equipotent doses through comparable delivery devices). [full review]

In adults and adolescents older than 12, strong evidence supports that monotherapy with ICSs is better than monotherapy with leukotriene modifiers. [full review]

In all individuals with poorly controlled asthma who are already on ICSs, the addition of a long-acting beta agonist (LABA) provides greater benefit than continuing on ICSs at the same or higher dose. [full review]

Currently, there is not enough evidence to replace the routine use of ICSs as first line therapy with a combination of an ICS and a LABA. In line with this evidence, FDA-approved prescribing information suggests that combination therapy should be reserved for patients whose asthma is not adequately controlled by a single medication such as long-term ICSs, or those who have severe asthma. [full review]

How do other controller drugs compare in treating asthma?

Overall, there appear to be no significant differences between:

• Leukotriene modifiers: montelukast and zafirlukast similarly decrease rescue medicine use and improve quality of life. [full review]
• Long-acting beta blockers: formoterol and salmeterol similarly control symptoms, prevent exacerbations, and improve quality of life in patients with asthma not controlled on ICSs alone. [full review]
• The addition of a LABA to ICS therapy provides more benefit than the addition of a leukotriene receptor antagonist. [full review]
• Combination therapy: budesonide/formoterol and fluticasone/salmeterol share similar efficacy and harms. [full review]

Omalizumab is the only anti-IgE drug currently approved for the treatment of asthma. Compared to placebo, it is superior in controlling asthma symptoms, preventing exacerbations, and reducing the need for rescue medication, but there is an increased risk of injection site reactions and anaphylaxis. [full review]

How do asthma controller drugs compare in safety?

Monotherapy with ICSs or leukotriene receptor antagonists is safer than monotherapy with LABAs. The risk of asthma-related death may be increased by monotherapy with LABAs, and they are not recommended nor approved for use as monotherapy. [full review]

Among the leukotriene modifiers, indirect evidence suggests that zileuton has an increased risk of liver toxicity compared with either montelukast or zafirlukast. [full review]

Among ICSs, no one drug is more harmful than the others [full review]. Moderate strength evidence suggests that there is no difference in overall adverse events between:

• ICSs vs. leukotriene modifiers [full review]
• ICSs and leukotriene receptor antagonists vs. ICSs and long-acting beta agonists [full review]
• ICSs and leukotriene receptor antagonists vs. increasing the dose of ICSs [full review]

Does young age influence the safety or effectiveness of asthma controller drugs?

In children aged 12 or younger:

• Monotherapy with ICSs is more effective than monotherapy with leukotriene modifiers.
• The addition of a LABA is better than continuing on ICSs alone in poorly controlled asthma.
• There is no difference in tolerability or overall adverse events between ICSs and leukotriene modifiers.
• Omalizumab may reduce asthma exacerbations in children with moderate to severe persistent asthma that is not adequately controlled with ICSs or ICSs combined with other asthma controller drugs.
• Evidence is lacking for children aged 4 years or younger. [full review]

ICSs may cause a very small decrease in the speed of growth in children, compared to placebo. This tends to occur in the first year of treatment, but there is not enough evidence to determine whether the final adult height is reduced. [full review]

For the influence of other patient factors on asthma controller drugs, such as ethnicity, gender, and smoking, please see the full review.

Drugs included in this review

Further Information

This PubMed Clinical Q&A was reviewed by Daniel E. Jonas, MD, MPH.

For the full report and evidence tables, please see:
Jonas DE, Wines R, DelMonte M, Amick H, Wilkins T, Einerson B, Schuler CL, Wynia BA, Bryant Shilliday B. Drug class review: Controller Medications for Asthma. Final update 1 report. [Internet]. Portland (OR): Oregon Health & Science University; 2011 April. Available at http://www.ncbi.nlm.nih.gov/books/n/cmasthma11/