Asthma – Controller vs. Rescue Medicines

(The following is for general information purposes.  For specific cases, consult your doctor.)

About 1 out of every 6 children have some degree of asthma and in the majority of those it is mild and intermittent.  The time between flare ups is often long (months or years) and patients/parents frequently forget how they should use/time/sequence the medicines.  I’m writing this to serve as a quick reference/review/cheat-sheet for those that need this refresher following a long asthma symptom free interval.  Improper usage of asthma medicines will not only make the treatment less effective but may increase the risk of side effects, some serious including death.

Rescue Medicines

Common rescue medicines include albuterol and xopenex.  The inhaled forms delivered either by a metered dose inhaler (MDI) or nebulizer work quickly (within minutes) and generally last a few hours (4 – 6).  If you are having asthma symptoms currently they can provide relatively immediate relief.

Controller Medicines

Common controller medicines include:

• inhaled topical corticosteroids(fluticasone/Flovent & Arnuity Ellipta, beclomethasone/Qvar, budesonide/Pulmicort, mometasone/Asmanex),
• montelukast/Singulair
• long acting beta 2 adrenergic drugs  (salmeterol, formoterol)

Controller Medicines take a while before they start working.  Some may take a few days to a week before you see their full effect.  Often, especially the inhaled topical steroids, are much more effective in reducing and preventing symptoms.  They last much longer with effects that can persist sometimes days instead of hours.

Generally the inhaled topical corticosteroids are preferred because they work much better and have minimal side effects.  These should not be confused with systemic corticosteroids that are swallowed or injected which have a far greater potential for serious side effects.

Some patients do better with a combination of controllers:

• Advair (fluticasone & salmeterol)
• Symbicort (budesinide & formoterol)
• Dulera (Mometasone & formoterol)
• AirDuo RespiClick (fluticasone propionate & salmeterol)
• Using Singulair in addition to another controller.

When to Use Rescue Medicines

The most common rescue medicine currently used is albuterol by meter dose inhaler (MDI).  Common brands include Ventolin and ProAir.  However, the recommendations below are general to all rescue meds (eg. albuterol delivered by a nebulizer)

1. Rescue Medicine without Controllers

• For prevention of exercise induced asthma.  For those who only have symptoms with exercise and if their asthma frequently occurs with exercise, the symptoms can sometimes be prevented by using the rescue medicine a few minutes prior to exercise.
• Regardless of the trigger, for those whose symptoms are very infrequent and can be treated effectively with no more than 2 doses per week of their rescue medicine.

2. Rescue Medicine with Controllers

• Those taking controller medicines that are currently having asthma symptoms (cough/wheeze) should take their rescue medicine also.

When to Use Controller Medicines

• Controller medicines should be used during the block of time of an asthma flare up
• The block of time varies and could be days, weeks or months.
• A general rule of thumb is if you have to use your rescue medicine more than 2 times in a week you can consider this an asthma flare-up and you should start your controller medicine.
• The controller medicine can be stopped after the block of time of the flare up.
• You may need about 1 week of being totally free of symptoms (cough, wheeze) to be reasonably sure the asthma flare-up is over.
• If after stopping the controller the symptoms return, resume taking the controller.

Common Scenarios

• A person who has not needed any medicine for 6 months is exposed to paint fumes and starts to cough and wheeze.  One dose of his rescue medicine effectively stops the symptoms and the symptoms don’t return.  No furthur treatment is needed.
• During Spring pollen season, a child has just required his 3rd rescue medicine treatment within a week.  He should now start his controller medicine.  He should continue it until he has been totally symptom free for a least a week.  The rescue medicine can be given as needed for active symptoms while he is taking the controller medicine.
• A child has been symtom free and off medicine for 9 months.  He catches a cold and his asthma begins to flare.  He should start his controller medicine and continue it until he has been symptom free for 2 to 3 weeks.  Studies show that abnormal pulmonary function can persist for weeks following a cold in people with asthma. The rescue medicine can be used in addition, as needed, to treat active symptoms.  Generally, “Cold Medicines” can be cautiously used in addition to asthma medicines, if needed.
• A child who tolerates exercise most of the time begins coughing and wheezing during a soccer match.  The rescue medicine controls the symptoms and they don’t recur.  No furthur treatment is needed.

If the Medicines Aren’t Working Well

• Verify you are using the correct medicines and timing and sequencing them correctly as described above.
• Check to see you are using the doses prescribed.
• If using a mist type metered dose inhaler be sure you are using it with a spacer and using the correct technique.  Even adults get a fraction of the dose if they don’t use a spacer.  If it is a small child who cannot form a seal over the mouthpiece, use the appropriate sized mask with the spacer.  How to use an Inhaler with a Spacer
• If you are using a powder type inhaler, be sure you are using the correct technique. How to use:
  • Pulmicort Flexhaler
  • Asmanex Twisthaler1  Twisthaler2
• If you are using a nebulizer, verify you are using the correct technique.  How to use a nebulizer
• If your symptoms are not improving with the prescribed treatment or are getting worse, call your doctor.

I welcome any suggestions for improving this article.