The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations of asthma in the emergency department is not discussed here.

The FDA is requiring stronger warnings in the labeling of the leukotriene receptor antagonist montelukast (Singulair, and generics) about the risk of suicidal behavior and other serious neuropsychiatric events associated with its use.

The FDA has approved Sinuva (Intersect ENT), a sinus implant that gradually releases the corticosteroid mometasone furoate over a 90-day period, for treatment of nasal polyps in adults who have had ethmoid sinus surgery. Propel, a sinus implant that releases mometasone furoate over 30 days, is FDA-approved to maintain the sinus opening after ethmoid sinus surgery; it is marketed by the same manufacturer as Sinuva.

The goal of asthma treatment is to control symptoms and prevent exacerbations. Management of acute exacerbations of asthma is not discussed here.

INHALATION DEVICES — Metered-dose inhalers (MDIs) require coordination of inhalation with hand-actuation of the device. Valved holding chambers (VHCs) or spacers help some patients, especially young children and the elderly, use MDIs effectively. VHCs have one-way valves that prevent the patient from exhaling into the device, minimizing the need for coordinated actuation and inhalation. Spacers are tubes or chambers placed between the canister and a face mask or mouthpiece, which also avoids the need to coordinate actuation and inhalation. Both VHCs and spacers retain the larger particles emitted from the MDI, decreasing their deposition in the oropharynx and leading to a higher proportion of small respirable particles being inhaled.

Inhalation is the preferred route of delivery for most asthma drugs. Chlorofluorocarbons (CFCs), which have ozone-depleting properties, are being phased out as propellants in metered-dose inhalers. Non-chlorinated hydrofluoroalkane (HFA) propellants, which do not deplete the ozone layer, are being used instead.

No truly new drugs have been approved for treatment of asthma since omalizumab (Xolair) in 2003, but some randomized controlled trials of older drugs have been published, and new guidelines have become available.

Patients with mild, infrequent asthma symptoms may require only intermittent, asneeded use of an inhaled short-acting beta2-adrenergic agonist. Use of a short-acting beta2-agonist more than twice weekly, other than for exercise-induced bronchospasm, indicates a need for anti-inflammatory treatment. Inhaled corticosteroids are the most effective anti-inflammatory medication; leukotriene modifiers are less effective alternatives. If regular use of an inhaled corticosteroid in a low dose does not prevent symptoms, a long-acting beta2-agonist should be added; addition of a second drug is more effective than raising the dose of the inhaled steroid. A leukotriene modifier can also be used as the second drug. Omalizumab may be considered as adjunctive therapy for patients more than 12 years old who have allergic asthma not controlled by other drugs. A short course of oral corticosteroids may be useful for acute exacerbations. Treatment of acute severe asthma as a medical emergency is not included here; it has been reviewed elsewhere (ER McFadden Jr, Am J Respir Crit Care Med 2003; 168:740).

Changes caused by one drug in the absorption, distribution, metabolism or excretion of another may lead to a pharmacokinetic adverse drug interaction (DN Juurlink et al, JAMA 2003; 289:1652). Additive drug interactions, such as vasodilation caused by both sildenafil (Viagra) and nitrates, can also have adverse effects.

New drug formulations continue to be introduced for the treatment of asthma, and new studies on older drugs continue to change our perspectives on the management of this chronic inflammatory disease. Treatment of asthma in the emergency department or hospital is not addressed here. More information on the diagnosis and treatment of asthma is available from Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda:NIH, 1997 and 2002 update; www.nhlbi.nih.gov).

Asthma is a chronic inflammatory disorder of the airways; inflammation caused by allergens, viral respiratory infections or other stimuli leads to bronchial hyperresponsiveness and obstruction of airflow. Anti-inflammatory drugs, particularly inhaled corticosteroids, are central to its management.

Celecoxib, a selective COX-2 inhibitor, has been approved by the FDA for treatment of osteoarthritis and rheumatoid arthritis.

Asthma is a chronic inflammatory disorder, with inflammation caused by allergens or other stimuli leading to bronchial hyperresponsiveness and obstruction of airflow.

Montelukast sodium (Singulair - Merck), a leukotriene receptor antagonist, has been approved by the US Food and Drug Administration (FDA) for oral prophylaxis and chronic treatment of asthma in adults and children at least 6 years old. It is the third 'leukotriene modifier' to become available in the USA; zafirlukast (Accolate - Medical Letter, 38:111, 1996) and zileuton (Zyflo - Medical Letter, 39:18, 1997) were marketed previously. Neither zafirlukast nor zileuton has been approved by the FDA for use in children less than 12 years old. Leukotriene modifiers are not recommended for treatment of an acute asthma attack (Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, Bethesda: NIH, 1997; www.nhlbi.NIH.gov/nhlbi/lung/ asthma/prof/asthgdln.htm).

Zileuton (zye loo' ton; Zyflo - Abbott), an inhibitor of leukotriene synthesis, has been approved by the US Food and Drug Administration (FDA) for prophylaxis and maintenance treatment of chronic asthma in adults and children more than 12 years old. A related drug—zafirlukast (Accolate), a leukotriene receptor antagonist—was recently reviewed in the Medical Letter (vol. 38, page 111, December 20, 1996). Neither of these drugs is recommended for treatment of acute asthma.

Zafirlukast (za fir loo kast; Accolate - Zeneca), the first leukotriene receptor anta-gonist approved by the US Food and Drug Administration, is now being heavily promoted for oral maintenance treatment of chronic asthma in patients more than 12 years old. It is not recommended for treatment of acute asthma.