Asthma is a chronic disease that causes inflammation or narrowing of the airways that carry the air you breathe in and out of your lungs. This can make it difficult to breathe and lead to wheezing (noisy breathing), coughing, shortness of breath, and a sensation of tightness in the chest. About 25 million Americans, including seven million children, have asthma, according to the National Heart, Lung, and Blood Institute. The disease usually first appears in childhood but adults can also develop it.
Asthma symptoms can be triggered by exposure to common allergens (such as animal dander, dust mites, and pollen) and irritants (such as certain chemicals, tobacco or wood smoke, and even cold air). Strenuous exercise, the common cold and the flu, certain drugs— such as aspirin and ibuprofen— and stress can also trigger asthma attacks.
Asthma symptoms range from mild to severe and doctors classify people with asthma according to the frequency and severity of their symptoms. (See Table 1 below.) The severity of your symptoms can vary; on some days they may be more severe than on others.
An important part of keeping your asthma symptoms under control is to figure out what your triggers are and avoid them. The chart shown on this page lists some common triggers and steps you can take to avoid or reduce your exposure. In some cases, allergy skin testing can help you identify your triggers.
Other things than can make asthma worse include sulfites in foods and beverages. These are commonly found in beer, wine, dried fruit, processed potatoes and shrimp, so avoid those if they trigger asthma attacks. For some people, cold air can be a trigger, so in that case, covering your nose and mouth with a scarf on cold days can help.
Medications, such as aspirin, ibuprofen and other non-steroidal anti-inflammatory drugs or NSAIDs, can also trigger attacks, so discuss with your doctor all the prescription and over-the-counter medications, vitamins, and dietary supplements you take.
One trigger you should not avoid is exercise. Although it can trigger an attack (known as exercise-induced bronchospasm), exercise is an important part of a healthy lifestyle. If it’s difficult for you to exercise because it triggers asthma symptoms, talk to your doctor about ways you can stay active. People with asthma might benefit from using their quick-acting inhaler medicine before exercise.
If an asthma attack makes you so short of breath that you’re having trouble walking and talking or your lips or fingernails turn blue, call 9-1-1. You may need emergency care at a hospital.
Budesonide suspension nebulizer (generic of Pulmicort Respules)
Beclomethasone (QVAR) is as effective and safe as other inhaled steroids, and it is the least expensive, ranging from $142 to $177 per month, depending on dose. But if you or your child needs a higher strength to control asthma symptoms, that can increase the cost.
We chose generic budesonide suspension nebulizer for children ages 1 year or older because it is the only inhaled steroid FDA-approved for children that young. Using the generic could save you between $98 and $168 when compared to its brand-name counterpart, Pulmicort Respules. But the generic is not available at the highest dose (1 mg/2 mL), so if your child needs a dose that high, you will have to opt for the brand name Pulmicort Respules, which is very expensive at a retail price of $778 per month.
Inhaled steroids are generally recommended as the first option for the treatment of persistent asthma symptoms in adults and children. This report focuses on the six inhaled steroid medicines that are available by prescription in the U.S.
Other medicines and approaches are used to treat asthma. All people with asthma should have a “quick relief” inhaler (also known as a short-acting inhaled beta 2-agonist, or SABA). These “quick relief” inhalers—which include albuterol (Proair HFA, Ventolin HFA) and levalbuterol (Xopenex)—act rapidly—within minutes—to open breathing passages, and provide relief for up to six hours. They are only used during an attack when breathing might be very difficult, and not—like inhaled steroids—everyday to keep symptoms and attacks at bay and your airways open.
There are also longer-acting bronchodilators (known as long-acting inhaled beta 2-agonists or LABAs), which can improve breathing for up to 12 hours. However, they have been linked to a higher risk of death during asthma attacks. They now carry a black box warning—the strongest kind—that they should only be used in people whose asthma is not adequately controlled by inhaled steroids alone. The LABAs should never be used without also using an inhaled steroid.
Two LABAs are available: salmeterol (Serevent Diskus) and formoterol (Foradil and Perforomist). Three other products combine these long-acting relievers with inhaled steroids: Advair Diskus and Advair HFA (both include a combination of salmeterol and fluticasone), Symbicort (a combination of budesonide and formoterol), and Dulera (a combination of mometasone and formoterol).
If your doctor prescribes any of the LABAs or combination products that contain a LABA, we urge you to discuss with him or her the safety issues that have been raised about those medications.
People with asthma may also take pills to help relieve their symptoms. For example, if you have asthma your doctor may prescribe a type of drug called a leukotriene receptor antagonist or LTRA, such as montelukast (Singulair and generic) or zafirlukast (Accolate and generic). There’s good evidence these drugs work, but they are not considered to be as effective as inhaled steroids at reducing the severity of symptoms or the frequency of asthma attacks.
If you have only intermittent and/or mild attacks that don’t really interfere with leading a normal life, your doctor may suggest you try to control the symptoms with a fast-acting reliever as needed, and not take an inhaled steroid unless your symptoms worsen. One sign of that would be if you find that you are using your quick-relief inhaler more than two times a week.
For the treatment of asthma, the effectiveness of the six inhaled steroids we evaluate is quite similar. Each reduces symptoms and prevents attacks by roughly the same amount, and none have been shown to be consistently better than the others in treating asthma in adults or children.
The inhaled steroid drugs differ in how convenient they are to use, the inhaler device in which they are packaged, their potency, and their cost. Your doctor and pharmacist can help guide you to one the fits your needs and preferences.
For instance, beclomethasone (QVAR) has a relatively low potency and, depending on the severity of your condition, it could take four to 16 puffs per day to get the required dose. By comparison, mometasone (Asmanex Twisthaler), which is more potent, requires only one to three puffs per day for an adult. For someone who needs a relatively high dose, a drug that requires you to take many puffs per day is inconvenient and may lower the benefit they can get from the drug. Also, if an inhaled steroid does not help or does not relieve your symptoms enough, current guidelines from the National Heart, Lung, and Blood Institute recommend adding a long-acting bronchodilator, such as salmeterol (Serevent Diskus) or formoterol (Foradil), so ask your doctor whether that makes sense in your case.
Second, inhaler devices differ. You may prefer one over another. Four of the medications—beclomethasone (QVAR), ciclesonide (Alvesco), flunisolide, and fluticasone (Flovent HFA)—are available in metered dose inhalers, also known as “puffers.” Three— budesonide (Pulmicort Flexhaler), fluticasone (Flovent Diskus) and mometasone (Asmanex Twisthaler)—are available as dry powder inhalers. And budesonide (Pulmicort Respules) is available as a nebulizer, which is used mostly for children. Your doctor can explain the differences and the pros and cons of each. Whichever type you choose, it is very important that you learn to use your inhaler properly. Studies have shown that many people don’t learn this and, as a result, don’t get optimal asthma control.
Age, Race, Gender, and Other Conditions
The effectiveness of inhaled steroids in treating asthma does not appear to differ based on age, gender, or race, or in people who have other diseases.
In five studies that compared inhaled steroids in children and teens with asthma, the effectiveness was the same as in adults. There have been no studies in children younger than six months. Most studies conducted in younger children—under four years— only compared budesonide to placebo, so there is little data on other inhaled steroids in young children. Budesonide (Pulmicort Respules) is the only inhaled steroid that has been proven effective in children as young as one year. Budesonide (Pulmicort Flexhaler) is FDA-approved for children six years and older. Both fluticasone and mometasone are FDA-approved for use in children four years and older, and QVAR is approved for children five and older.)
Minor (usually go away in time or are short-lived)
Serious (rare but can be dangerous)
More common in older people (these particularly affect women, but are not dangerous)
Like most medicines, the inhaled steroids can cause side effects. The most common are mouth and throat irritation, cough, and hoarseness. Those are usually minor and tolerable. Other side effects include mouth or throat infections (called thrush or oropharyngeal candidiasis). Using a spacer device and thoroughly rinsing your mouth with water after each inhaler use might reduce the risk of these infections.
Some studies have linked inhaled steroids to an increased risk of osteoporosis, or weakening of the bones. But experts continue to debate whether this research is valid and many studies have found no link between using inhaled steroids and loss of bone density or an increased risk of bone fractures. Still, if you are over 50 and use inhaled steroids, you should discuss with your doctor whether to take calcium and vitamin D supplements and have occasional bone density measurements as a precaution.
There have been reports of eye problems, including glaucoma and cataracts, reported in people who had taken high doses of inhaled steroids for a long time. Tell your doctor if you have previously had those conditions or notice a change in your vision while taking an inhaled steroid.
All of the inhaled steroids, except budesonide, have been linked to birth defects in animal studies when given during pregnancy, but there is limited information available about the effect of these medications in pregnant women. So inhaled steroids should only be used during pregnancy if the beneficial effects are believed to outweigh the potential harms. Poorly controlled asthma during pregnancy—which could lead to lower oxygen levels in your blood and for your baby—has been associated with higher rates of premature birth, lower birth weight, and prenatal death. Proper use of inhaled steroids is thought to reduce the potential for those problems. So if you are pregnant and have asthma, ask your doctor whether you should continue to take your inhaled steroid. Pregnancy increases the production of corticosteroids in the body, so some women may be able to use a lower dose of inhaled steroid while pregnant or stop using the medication.
Some inhaled steroids can interact with certain antifungal drugs, such as ketoconazole, and HIV medications. So, be sure to tell your doctor about any medications or supplements you take.
Many people try alternative therapies for asthma, such as acupuncture, diets, herbs or vitamins, and homeopathic remedies. Very little research has been done on these treatments but the available studies indicate they are ineffective. And some—such as herbal ephedra—can be dangerous. The FDA has now banned ephedra.
Everyone with asthma should have readily available a “quick relief” inhaler (or SABA), but not everyone with asthma needs an inhaled steroid drug. Sometimes, lifestyle adjustments, including quitting smoking and avoiding exposure to triggers, such as pet dander or mold, work well enough that an inhaled steroid isn’t necessary. But most people with asthma—including children—will probably need some kind of controller medicine, and an inhaled steroid drug in particular.
Consumer Reports. Treating Asthma with Inhaled Steroids. Comparing effectiveness, safety, and price. Published November 2013.