Long-acting reliever inhaler
If your asthma does not respond to treatment, the dose of preventer inhaler can be increased in discussion with your healthcare team. If this does not control your asthma symptoms, you may be given an inhaler containing a medicine called a long-acting reliever (long-acting bronchodilator/long acting beta2-agonist or LABA) to take as well. Or you may be given an inhaler combining an inhaled steroid and a long-acting bronchodilator in the one device, called a ‘combination’ inhaler. These work in the same way as short-acting relievers, but they take longer to work and can last up to 12 hours. Examples of long-acting reliever inhalers include formoterol and salmeterol.
Only use your long-acting reliever inhaler in combination with the preventer inhaler and never by itself. Studies have shown that using only a long-acting reliever can increase the chance of an asthma attack and can even increase the risk of death. Examples of combination inhalers include Seretide, Symbicort and Fostair. These are usually purple, red and white, or maroon.
Preventer medicines
If treatment of your asthma is still not successful, additional preventer medicines will be tried. Two possible alternatives include:
- leukotriene receptor antagonists (montelukast): tablets that block part of the chemical reaction involved in inflammation of the airways
- theophyllines: tablets that help widen the airways by relaxing the muscles around them
If your asthma is still not under control, you may be prescribed regular oral steroids (steroid tablets). This treatment is usually monitored by a respiratory specialist (a specialist in asthma). Long-term use of oral steroids has possible serious side effects, so they are only used once other treatment options have been tried. See below for more information on the side effects of steroid tablets.
Occasional use of oral steroids
Most people only need to take a course of oral steroids for one or two weeks. Once your asthma is under control, you can be 'stepped-down' to your previous treatment.
Omalizumab (Xolair)
Omalizumab, also known as Xolair, is the first of a new category of drugs. It binds to one of the proteins involved in the immune response and reduces its level in the blood. This reduces the chance of an immune reaction happening. The National Institute for Heath and Clinical Excellence (NICE) recommends that omalizumab can be used in people with frequent severe asthma attacks which require visits to A&E or hospital admission.
Omalizumab is given as an injection every two to four weeks. It should only be prescribed in a specialist centre. If omalizumab does not control asthma symptoms within 16 weeks, the treatment should be stopped.
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Bronchial thermoplasty
Bronchial thermoplasty is a relatively new procedure not yet widely available. In some cases it may be used to treat severe asthma by reducing airway narrowing.
The procedure is carried out either with sedation or under general anaesthetic. A bronchoscope (a type of hollow tube) containing a probe is inserted through the mouth or nose into the airway and expanded so it touches the airway wall, it then heats up. Three treatment sessions are usually needed with at least three weeks between each session.
There is some evidence to show this procedure may reduce asthma attacks and improve the quality of life of someone with severe asthma. However, the long-term risks and benefits are not yet fully understood.
You should discuss this procedure fully with your clinician if the treatment is offered.
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