Asthma: Principles of treatment

The goals of treatment are prevention of fatalities, hospitalizations, and emergency department visits, along with achieving good long-term control of asthma, with reduction of symptoms, maintenance of normal activity level, prevention of exacerbations, and accelerated loss of pulmonary function (forced expiratory volume in 1 second [FEV₁]) as well as avoiding harm from therapies. Treatment often is initiated based on severity of symptoms, physical examination findings, and, for some patients, the FEV₁ or peak expiratory flow rates. Comorbidities such as gastroesophageal reflux disease and laryngopharyngeal reflux, rhinitis or rhinosinusitis, sleep apnea, recurrent infections, smoking, and substance abuse should be addressed. Two treatment modalities are indicated only for individuals with allergic asthma: allergen-specific immunotherapy, commonly known as allergy shots, and omalizumab. Allergen immunotherapy is effective in decreasing symptoms and medication use in selected patients with mild-to-moderate allergic asthma. In addition, patients receiving allergen immunotherapy for allergic rhinitis may have a decreased risk of developing asthma. Omalizumab, a recombinant humanized monoclonal anti-IgE antibody indicated for persistent moderate-to-severe allergic asthma, has been shown to improve asthma-related quality of life, decrease clinically significant exacerbation rates, number of courses of oral corticosteroids, and reduce the severity of exacerbations. It is administered every 2-4 weeks subcutaneously, and improvement should be ascertained after 4-6 months.