Editing Asthma (section)

==Management==
While there is no cure for asthma, symptoms can typically be improved.<ref>{{cite book| vauthors = Ripoll BC, Leutholtz I |title=Exercise and disease management|publisher=CRC Press|location=Boca Raton|isbn=978-1-4398-2759-8|pages = 100|url=https://books.google.com/books?id=eAn9-bm_pi8C&pg=PA100|edition=2nd |date=2011 |url-status=live|archive-url=https://web.archive.org/web/20160506213238/https://books.google.com/books?id=eAn9-bm_pi8C&pg=PA100|archive-date=May 6, 2016}}</ref> The most effective treatment for asthma is identifying triggers, such as [[Health effects of tobacco smoking|cigarette smoke]], use of [[electronic cigarette]]s, pets or other allergens, and eliminating exposure to them.<ref>{{cite web |last1=Bhatta |first1=Dharma N. |last2=Glantz |first2=Stanton A. |title=Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis |url=https://www.ajpmonline.org/article/S0749-3797(19)30391-5/abstract |website=American Journal of Preventive Medicine |pages=182–190 |language=English |doi=10.1016/j.amepre.2019.07.028 |date=February 2020}}</ref> If trigger avoidance is insufficient, the use of medication is recommended. Pharmaceutical drugs are selected based on, among other things, the severity of illness and the frequency of symptoms. Specific medications for asthma are broadly classified into fast-acting and long-acting categories.<ref name="NHLBI07p213">{{harvnb|NHLBI Guideline|2007|p=213}}</ref><ref name=BGMA08>{{cite web |url=http://www.sign.ac.uk/pdf/sign101.pdf |title=British Guideline on the Management of Asthma|publisher=Scottish Intercollegiate Guidelines Network |year=2008 |access-date=August 4, 2008| archive-url= https://web.archive.org/web/20080819203455/http://www.sign.ac.uk/pdf/sign101.pdf| archive-date= August 19, 2008 | url-status= live}}</ref> The medications listed below have demonstrated efficacy in improving asthma symptoms; however, real world use-effectiveness is limited as around half of people with asthma worldwide remain sub-optimally controlled, even when treated.<ref>{{cite journal | vauthors = Rabe KF, Adachi M, Lai CK, Soriano JB, Vermeire PA, Weiss KB, Weiss ST | title = Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys | journal = The Journal of Allergy and Clinical Immunology | volume = 114 | issue = 1 | pages = 40–47 | date = July 2004 | pmid = 15241342 | doi = 10.1016/j.jaci.2004.04.042 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Demoly P, Gueron B, Annunziata K, Adamek L, Walters RD | title = Update on asthma control in five European countries: results of a 2008 survey | journal = European Respiratory Review | volume = 19 | issue = 116 | pages = 150–157 | date = June 2010 | pmid = 20956184 | pmc = 9682581 | doi = 10.1183/09059180.00002110 | s2cid = 13408225 | doi-access = free }}</ref><ref>{{cite journal | vauthors = FitzGerald JM, Boulet LP, McIvor RA, Zimmerman S, Chapman KR | title = Asthma control in Canada remains suboptimal: the Reality of Asthma Control (TRAC) study | journal = Canadian Respiratory Journal | volume = 13 | issue = 5 | pages = 253–259 |year = 2006 | pmid = 16896426 | pmc = 2683303 | doi = 10.1155/2006/753083 | doi-access = free }}</ref> People with asthma may remain sub-optimally controlled either because optimum doses of asthma medications do not work (called "refractory" asthma) or because individuals are either unable (e.g. inability to afford treatment, poor inhaler technique) or unwilling (e.g., wish to avoid side effects of corticosteroids) to take optimum doses of prescribed asthma medications (called "difficult to treat" asthma). In practice, it is not possible to distinguish "refractory" from "difficult to treat" categories for patients who have never taken optimum doses of asthma medications. A related issue is that the asthma efficacy trials upon which the pharmacological treatment guidelines are based have systematically excluded the majority of people with asthma.<ref>{{cite journal | vauthors = Herland K, Akselsen JP, Skjønsberg OH, Bjermer L | title = How representative are clinical study patients with asthma or COPD for a larger 'real life' population of patients with obstructive lung disease? | journal = Respiratory Medicine | volume = 99 | issue = 1 | pages = 11–19 | date = January 2005 | pmid = 15672843 | doi = 10.1016/j.rmed.2004.03.026 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Travers J, Marsh S, Williams M, Weatherall M, Caldwell B, Shirtcliffe P, Aldington S, Beasley R | display-authors = 6 | title = External validity of randomised controlled trials in asthma: to whom do the results of the trials apply? | journal = Thorax | volume = 62 | issue = 3 | pages = 219–223 | date = March 2007 | pmid = 17105779 | pmc = 2117157 | doi = 10.1136/thx.2006.066837 }}</ref> For example, asthma efficacy treatment trials always exclude otherwise eligible people who smoke, and smoking diminishes the efficacy of inhaled corticosteroids, the mainstay of asthma control management.<ref>{{cite journal | vauthors = Lazarus SC, Chinchilli VM, Rollings NJ, Boushey HA, Cherniack R, Craig TJ, Deykin A, DiMango E, Fish JE, Ford JG, Israel E, Kiley J, Kraft M, Lemanske RF, Leone FT, Martin RJ, Pesola GR, Peters SP, Sorkness CA, Szefler SJ, Wechsler ME, Fahy JV | display-authors = 6 | title = Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in asthma | journal = American Journal of Respiratory and Critical Care Medicine | volume = 175 | issue = 8 | pages = 783–790 | date = April 2007 | pmid = 17204725 | pmc = 1899291 | doi = 10.1164/rccm.200511-1746OC }}</ref><ref>{{cite journal | vauthors = Stapleton M, Howard-Thompson A, George C, Hoover RM, Self TH | title = Smoking and asthma | journal = Journal of the American Board of Family Medicine | volume = 24 | issue = 3 | pages = 313–322 |year = 2011 | pmid = 21551404 | doi = 10.3122/jabfm.2011.03.100180 | s2cid = 3183714 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Hayes CE, Nuss HJ, Tseng TS, Moody-Thomas S | title = Use of asthma control indicators in measuring inhaled corticosteroid effectiveness in asthmatic smokers: a systematic review | journal = The Journal of Asthma | volume = 52 | issue = 10 | pages = 996–1005 |year = 2015 | pmid = 26418843 | doi = 10.3109/02770903.2015.1065422 | s2cid = 36916271 }}</ref>

[[Bronchodilators]] are recommended for short-term relief of symptoms.<!-- <ref name=NAEPP/> --> In those with occasional attacks, no other medication is needed.<!-- <ref name=NAEPP/> --> If mild persistent disease is present (more than two attacks a week), low-dose inhaled corticosteroids or alternatively, a [[leukotriene antagonist]] or a [[mast cell stabilizer]] by mouth is recommended.<!-- <ref name=NAEPP/> --> For those who have daily attacks, a higher dose of inhaled corticosteroids is used. In a moderate or severe exacerbation, corticosteroids by mouth are added to these treatments.<ref name="NHLBI07p214" />

People with asthma have higher rates of [[anxiety]], [[psychological stress]], and [[Depression (mood)|depression]].<ref name=Kew2016/><ref>{{cite journal | vauthors = Paudyal P, Hine P, Theadom A, Apfelbacher CJ, Jones CJ, Yorke J, Hankins M, Smith HE | display-authors = 6 | title = Written emotional disclosure for asthma | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD007676 | date = May 2014 | pmid = 24842151 | doi = 10.1002/14651858.CD007676.pub2 | pmc = 11254376 }}</ref> This is associated with poorer asthma control.<ref name=Kew2016/> [[Cognitive behavioural therapy]] may improve quality of life, asthma control, and anxiety levels in people with asthma.<ref name=Kew2016>{{cite journal | vauthors = Kew KM, Nashed M, Dulay V, Yorke J | title = Cognitive behavioural therapy (CBT) for adults and adolescents with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD011818 | date = September 2016 | issue = 9 | pmid = 27649894 | pmc = 6457695 | doi = 10.1002/14651858.CD011818.pub2 }}</ref>

Improving people's knowledge about asthma and using a written action plan has been identified as an important component of managing asthma.<ref>{{cite journal | vauthors = Bhogal S, Zemek R, Ducharme FM | title = Written action plans for asthma in children | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD005306 | date = July 2006 | pmid = 16856090 | doi = 10.1002/14651858.CD005306.pub2 }}</ref> Providing educational sessions that include information specific to a person's culture is likely effective.<ref name="McCallumMorris2017">{{cite journal | vauthors = McCallum GB, Morris PS, Brown N, Chang AB | title = Culture-specific programs for children and adults from minority groups who have asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD006580 | date = August 2017 | issue = 8 | pmid = 28828760 | pmc = 6483708 | doi = 10.1002/14651858.CD006580.pub5 }}</ref> More research is necessary to determine if increasing preparedness and knowledge of asthma among school staff and families using home-based and school interventions results in long term improvements in safety for children with asthma.<ref>{{cite journal | vauthors = Kew KM, Carr R, Donovan T, Gordon M | title = Asthma education for school staff | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012255 | date = April 2017 | issue = 4 | pmid = 28402017 | pmc = 6478185 | doi = 10.1002/14651858.CD012255.pub2 }}</ref><ref>{{cite journal | vauthors = Welsh EJ, Hasan M, Li P | title = Home-based educational interventions for children with asthma | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD008469 | date = October 2011 | volume = 2014 | pmid = 21975783 | doi = 10.1002/14651858.CD008469.pub2 | pmc = 8972064 }}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/39912443|date = March 2025}}<ref>{{cite journal | vauthors = Yorke J, Shuldham C | title = Family therapy for chronic asthma in children | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD000089 | date = April 2005 | volume = 2005 | pmid = 15846599 | doi = 10.1002/14651858.CD000089.pub2 | pmc = 7038646 }}</ref> School-based asthma self-management interventions, which attempt to improve knowledge of asthma, its triggers and the importance of regular practitioner review, may reduce hospital admissions and emergency department visits. These interventions may also reduce the number of days children experience asthma symptoms and may lead to small improvements in asthma-related quality of life.<ref>{{cite journal | vauthors = Harris K, Kneale D, Lasserson TJ, McDonald VM, Grigg J, Thomas J | title = School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD011651 | date = January 2019 | issue = 1 | pmid = 30687940 | pmc = 6353176 | doi = 10.1002/14651858.CD011651.pub2 | collaboration = Cochrane Airways Group }}</ref> More research is necessary to determine if [[Shared decision-making in medicine|shared decision-making]] is helpful for managing adults with asthma<ref>{{cite journal | vauthors = Kew KM, Malik P, Aniruddhan K, Normansell R | title = Shared decision-making for people with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD012330 | date = October 2017 | issue = 10 | pmid = 28972652 | pmc = 6485676 | doi = 10.1002/14651858.CD012330.pub2 }}</ref> or if a personalized asthma action plan is effective and necessary.<ref>{{cite journal | vauthors = Gatheral TL, Rushton A, Evans DJ, Mulvaney CA, Halcovitch NR, Whiteley G, Eccles FJ, Spencer S | display-authors = 6 | title = Personalised asthma action plans for adults with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD011859 | date = April 2017 | issue = 4 | pmid = 28394084 | pmc = 6478068 | doi = 10.1002/14651858.CD011859.pub2 }}</ref> Some people with asthma use [[Pulse oximetry|pulse oximeters]] to monitor their own blood oxygen levels during an asthma attack. However, there is no evidence regarding the use in these instances.<ref>{{cite journal | vauthors = Welsh EJ, Carr R | title = Pulse oximeters to self monitor oxygen saturation levels as part of a personalised asthma action plan for people with asthma | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD011584 | date = September 2015 | volume = 2015 | pmid = 26410043 | doi = 10.1002/14651858.CD011584.pub2 | pmc = 9426972 |collaboration = Cochrane Airways Group }}</ref>

===Lifestyle modification===
Avoidance of triggers is a key component of improving control and preventing attacks. The most common triggers include [[allergen]]s, smoke (from tobacco or other sources), air pollution, [[Beta blocker#Nonselective agents|nonselective beta-blockers]], and sulfite-containing foods.<ref name=NAEPP2007p69>{{harvnb|NHLBI Guideline|2007|p=69}}</ref><ref name=thomson>{{cite journal | vauthors = Thomson NC, Spears M | title = The influence of smoking on the treatment response in patients with asthma | journal = Current Opinion in Allergy and Clinical Immunology | volume = 5 | issue = 1 | pages = 57–63 | date = February 2005 | pmid = 15643345 | doi = 10.1097/00130832-200502000-00011 | s2cid = 25065026 }}</ref> Cigarette smoking and [[second-hand smoke]] (passive smoke) may reduce the effectiveness of medications such as corticosteroids.<ref name=Stap2011>{{cite journal | vauthors = Stapleton M, Howard-Thompson A, George C, Hoover RM, Self TH | title = Smoking and asthma | journal = Journal of the American Board of Family Medicine | volume = 24 | issue = 3 | pages = 313–322 |year=2011 | pmid = 21551404 | doi = 10.3122/jabfm.2011.03.100180 | doi-access = free }}</ref> [[Smoking ban|Laws that limit smoking]] decrease the number of people hospitalized for asthma.<ref name="Effect of smoke-free legislation on" /> Dust mite control measures, including air filtration, chemicals to kill mites, vacuuming, mattress covers and other methods had no effect on asthma symptoms.<ref name=Gotzsche2008>{{cite journal | vauthors = Gøtzsche PC, Johansen HK | title = House dust mite control measures for asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2008 | issue = 2 | pages = CD001187 | date = April 2008 | pmid = 18425868 | pmc = 8786269 | doi = 10.1002/14651858.CD001187.pub3 | author-link1 = Peter C. Gøtzsche }}</ref> There is insufficient evidence to suggest that dehumidifiers are helpful for controlling asthma.<ref>{{cite journal | vauthors = Singh M, Jaiswal N | title = Dehumidifiers for chronic asthma | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD003563 | date = June 2013 | volume = 2014 | pmid = 23760885 | doi = 10.1002/14651858.CD003563.pub2 | pmc = 10646756 }}</ref>

Overall, exercise is beneficial in people with stable asthma.<ref>{{cite journal | vauthors = Carson KV, Chandratilleke MG, Picot J, Brinn MP, Esterman AJ, Smith BJ | title = Physical training for asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2013 | issue = 9 | pages = CD001116 | date = September 2013 | pmid = 24085631 | doi = 10.1002/14651858.CD001116.pub4 | pmc = 11930393 }}</ref> Yoga could provide small improvements in quality of life and symptoms in people with asthma.<ref>{{cite journal | vauthors = Yang ZY, Zhong HB, Mao C, Yuan JQ, Huang YF, Wu XY, Gao YM, Tang JL | display-authors = 6 | title = Yoga for asthma | journal = The Cochrane Database of Systematic Reviews | volume = 4 | pages = CD010346 | date = April 2016 | issue = 11 | pmid = 27115477 | pmc = 6880926 | doi = 10.1002/14651858.cd010346.pub2 }}</ref> More research is necessary to determine how effective weight loss is in improving quality of life, the usage of health care services, and adverse effects for people of all ages with asthma.<ref>{{cite journal | vauthors = Adeniyi FB, Young T | title = Weight loss interventions for chronic asthma | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD009339 | date = July 2012 | pmid = 22786526 | doi = 10.1002/14651858.CD009339.pub2 | pmc = 12075998 }}</ref><ref>{{cite journal | vauthors = Cheng J, Pan T, Ye GH, Liu Q | title = Calorie controlled diet for chronic asthma | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD004674 | date = July 2005 | pmid = 16034941 | doi = 10.1002/14651858.CD004674.pub2 }}</ref>

Findings suggest that the [[Wim Hof]] Method may reduce inflammation in healthy and non-healthy participants as it increases epinephrine levels, causing an increase in interleukin-10 and a decrease in pro-inflammatory cytokines.<ref>{{Cite journal |last1=Almahayni |first1=Omar |last2=Hammond |first2=Lucy |date=March 13, 2024 |title=Does the Wim Hof Method have a beneficial impact on physiological and psychological outcomes in healthy and non-healthy participants? A systematic review |journal=PLOS ONE |volume=19 |issue=3 |pages=e0286933 |doi=10.1371/journal.pone.0286933 |doi-access=free |issn=1932-6203 |pmid=38478473|pmc=10936795 |bibcode=2024PLoSO..1986933A }}</ref>

===Medications<span class="anchor" id="Anti-asthmatic"></span>===
Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation.<ref name="NHLBI07p213" /> [[Antibiotic]]s are generally not needed for sudden worsening of symptoms or for treating asthma at any time.<ref>{{cite web|title=QRG 153 • British guideline on the management of asthma|url=http://www.sign.ac.uk/pdf/QRG153.pdf|website=SIGN|access-date=October 6, 2016|date=September 2016|url-status=live|archive-url=https://web.archive.org/web/20161009122108/http://www.sign.ac.uk/pdf/QRG153.pdf|archive-date=October 9, 2016}}</ref><ref>{{cite journal | vauthors = Normansell R, Sayer B, Waterson S, Dennett EJ, Del Forno M, Dunleavy A | title = Antibiotics for exacerbations of asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | pages = CD002741 | date = June 2018 | issue = 6 | pmid = 29938789 | pmc = 6513273 | doi = 10.1002/14651858.CD002741.pub2 }}</ref>

====Medications for asthma exacerbations====
[[File:Salbutamol2.JPG|thumb|upright|alt=A round canister above a blue plastic holder|[[Salbutamol]] metered dose inhaler commonly used to treat asthma attacks]]

* Short-acting [[Beta2-adrenergic agonist|beta<sub>2</sub>-adrenoceptor agonists]] (SABAs), such as [[salbutamol]] (''albuterol'' [[United States Adopted Name|USAN]]) are the first-line treatment for asthma symptoms.<ref name="NHLBI07p214" /> They are recommended before exercise in those with exercise-induced symptoms.<ref>{{cite journal |vauthors=Parsons JP, Hallstrand TS, Mastronarde JG, Kaminsky DA, Rundell KW, Hull JH, Storms WW, Weiler JM, Cheek FM, Wilson KC, Anderson SD |display-authors=6 |title=An Official American Thoracic Society Clinical Practice Guideline: Exercise-Induced Bronchoconstriction |journal=American Journal of Respiratory and Critical Care Medicine |volume=187 |issue=9 |pages=1016–1027 |date=May 2013 |pmid=23634861 |doi=10.1164/rccm.201303-0437ST }}</ref>
* [[Anticholinergic]] medications, such as [[ipratropium]], provide additional benefit when used in combination with SABA in those with moderate or severe symptoms and may prevent hospitalizations.<ref name="NHLBI07p214" /><ref name="Griffiths_2013">{{cite journal | vauthors = Griffiths B, Ducharme FM | title = Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD000060 | date = August 2013 | pmid = 23966133 | doi = 10.1002/14651858.CD000060.pub2 | pmc = 12047668 }}</ref><ref name="Kirkland_2017">{{cite journal | vauthors = Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH | title = Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD001284 | date = January 2017 | issue = 1 | pmid = 28076656 | pmc = 6465060 | doi = 10.1002/14651858.CD001284.pub2 }}</ref> Anticholinergic bronchodilators can also be used if a person cannot tolerate a SABA.<ref name="Self, Timothy 2009" /> If a child requires admission to hospital additional ipratropium does not appear to help over a SABA.<ref>{{cite journal | vauthors = Vézina K, Chauhan BF, Ducharme FM | title = Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital | journal = The Cochrane Database of Systematic Reviews | volume = 2014 | issue = 7 | pages = CD010283 | date = July 2014 | pmid = 25080126 | doi = 10.1002/14651858.CD010283.pub2 | pmc = 10772940 }}</ref> For children over 2 years old with acute asthma symptoms, inhaled anticholinergic medications taken alone is safe but is not as effective as inhaled SABA or SABA combined with inhaled anticholinergic medication.<ref>{{cite journal | vauthors = Teoh L, Cates CJ, Hurwitz M, Acworth JP, van Asperen P, Chang AB | title = Anticholinergic therapy for acute asthma in children | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD003797 | date = April 2012 | pmid = 22513916 | doi = 10.1002/14651858.CD003797.pub2 | pmc = 11329281 | url = https://espace.library.uq.edu.au/view/UQ:274872/UQ274872_OA.pdf }}</ref><ref name="Griffiths_2013" /> Adults who receive combined inhaled medications, which include short-acting anticholinergics and SABA, may be at risk for increased adverse effects such as experiencing a tremor, agitation, and heart beat [[palpitations]] compared to people who are treated with SABAs alone.<ref name="Kirkland_2017" />
* Older, less selective [[adrenergic receptor|adrenergic agonists]], such as inhaled [[epinephrine (medication)|epinephrine]], have similar efficacy to SABAs.<ref name="Rodrigo">{{cite journal | vauthors = Rodrigo GJ, Nannini LJ | title = Comparison between nebulized adrenaline and beta2 agonists for the treatment of acute asthma. A meta-analysis of randomized trials | journal = The American Journal of Emergency Medicine | volume = 24 | issue = 2 | pages = 217–22 | date = March 2006 | pmid = 16490653 | doi = 10.1016/j.ajem.2005.10.008 }}</ref> They are, however, not recommended due to concerns regarding excessive cardiac stimulation.<ref name="NHLBI07p351">{{harvnb|NHLBI Guideline|2007|p=351}}</ref>
* Corticosteroids can also help with the acute phase of an exacerbation because of their antiinflammatory properties. The benefit of systemic and oral corticosteroids is well established. Inhaled or nebulized corticosteroids can also be used.<ref name="BertrandSánchez2020" /> For adults and children who are in the hospital due to acute asthma, systemic (IV) corticosteroids improve symptoms.<ref>{{cite journal | vauthors = Smith M, Iqbal S, Elliott TM, Everard M, Rowe BH | title = Corticosteroids for hospitalised children with acute asthma | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD002886 |year = 2003 | volume = 2003 | pmid = 12804441 | doi = 10.1002/14651858.CD002886 | pmc = 6999806 }}</ref><ref>{{cite journal | vauthors = Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW | title = Early emergency department treatment of acute asthma with systemic corticosteroids | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002178 |year = 2001 | pmid = 11279756 | doi = 10.1002/14651858.CD002178 | pmc = 7025797 }}</ref> A short course of corticosteroids after an acute asthma exacerbation may help prevent relapses and reduce hospitalizations.<ref>{{cite journal | vauthors = Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW | title = Corticosteroids for preventing relapse following acute exacerbations of asthma | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD000195 | date = July 2007 | pmid = 17636617 | doi = 10.1002/14651858.CD000195.pub2 | s2cid = 11992578 }}</ref>
* Other remedies, less established, are intravenous or nebulized magnesium sulfate and helium mixed with oxygen. Aminophylline could be used with caution as well.<ref name="BertrandSánchez2020" />
* Mechanical ventilation is the last resort in case of severe hypoxemia.<ref name="BertrandSánchez2020" />
* Intravenous administration of the drug [[aminophylline]] does not provide an improvement in bronchodilation when compared to standard inhaled beta<small><sub>2</sub></small> agonist treatment.<ref name=Nai2012>{{cite journal | vauthors = Nair P, Milan SJ, Rowe BH | title = Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | pages = CD002742 | date = December 2012 | issue = 12 | pmid = 23235591 | doi = 10.1002/14651858.CD002742.pub2 | pmc = 7093892 }}</ref> Aminophylline treatment is associated with more adverse effects compared to inhaled beta<sub><small>2</small></sub> agonist treatment.<ref name=Nai2012/>

==== Long–term control ====
[[File:Fluticasone.JPG|thumb|upright|alt=A round canister above an orange plastic holder|[[Fluticasone propionate]] metered dose inhaler commonly used for long-term control]]

* Corticosteroids are generally considered the most effective treatment available for long-term control.<ref name=NHLBI07p213/> Inhaled forms are usually used except in the case of severe persistent disease, in which oral corticosteroids may be needed.<ref name=NHLBI07p213/> Dosage depends on the severity of symptoms.<ref name="NHLBI07p218">{{harvnb|NHLBI Guideline|2007|p=218}}</ref> High dosage and long-term use might lead to the appearance of common adverse effects which are  growth delay, adrenal suppression, and osteoporosis.<ref name="BertrandSánchez2020" /> Continuous (daily) use of an inhaled corticosteroid, rather than its intermitted use, seems to provide better results in controlling asthma exacerbations.<ref name="BertrandSánchez2020" /> Commonly used corticosteroids are  [[budesonide]], [[fluticasone]], [[mometasone]] and [[ciclesonide]].<ref name="BertrandSánchez2020" />
* [[Long-acting beta-adrenoceptor agonist]]s (LABA) such as [[salmeterol]] and [[formoterol]] can improve asthma control, at least in adults, when given in combination with inhaled corticosteroids.<ref name=Ducharme2010>{{cite journal | vauthors = Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ | title = Addition of long-acting beta2-agonists to inhaled corticosteroids versus same dose inhaled corticosteroids for chronic asthma in adults and children | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD005535 | date = May 2010 | pmid = 20464739 | pmc = 4169792 | doi = 10.1002/14651858.CD005535.pub2 | veditors = Ducharme FM }}</ref><ref name=Duc2009>{{cite journal | vauthors = Ni Chroinin M, Greenstone I, Lasserson TJ, Ducharme FM | title = Addition of inhaled long-acting beta2-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults and children | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005307 | date = October 2009 | pmid = 19821344 | pmc = 4170786 | doi = 10.1002/14651858.CD005307.pub2 }}</ref> In children this benefit is uncertain.<ref name=Ducharme2010/><ref name="pmid20393943">{{cite journal | vauthors = Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ | title = Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005533 | date = April 2010 | pmid = 20393943 | pmc = 4169793 | doi = 10.1002/14651858.CD005533.pub2 | veditors = Ducharme FM }}</ref><ref name=Duc2009/> When used without steroids they increase the risk of severe [[side-effect]]s,<ref name=Fanta2009>{{cite journal | vauthors = Fanta CH | title = Asthma | journal = The New England Journal of Medicine | volume = 360 | issue = 10 | pages = 1002–14 | date = March 2009 | pmid = 19264689 | doi = 10.1056/NEJMra0804579 }}</ref> and with corticosteroids they may slightly increase the risk.<ref name=Cates2012>{{cite journal | vauthors = Cates CJ, Cates MJ | title = Regular treatment with formoterol for chronic asthma: serious adverse events | journal = The Cochrane Database of Systematic Reviews | volume = 4 | issue = 4 | pages = CD006923 | date = April 2012 | pmid = 22513944 | pmc = 4017186 | doi = 10.1002/14651858.CD006923.pub3 | veditors = Cates CJ }}</ref><ref name="pmid18646149">{{cite journal | vauthors = Cates CJ, Cates MJ | title = Regular treatment with salmeterol for chronic asthma: serious adverse events | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD006363 | date = July 2008 | pmid = 18646149 | pmc = 4015854 | doi = 10.1002/14651858.CD006363.pub2 | veditors = Cates CJ }}</ref> Evidence suggests that for children who have persistent asthma, a treatment regime that includes LABA added to inhaled corticosteroids may improve lung function but does not reduce the amount of serious exacerbations.<ref name=Chau2015>{{cite journal | vauthors = Chauhan BF, Chartrand C, Ni Chroinin M, Milan SJ, Ducharme FM | title = Addition of long-acting beta2-agonists to inhaled corticosteroids for chronic asthma in children | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD007949 | date = November 2015 | volume = 2015 | pmid = 26594816 | pmc = 4167878 | doi = 10.1002/14651858.CD007949.pub2 }}</ref> Children who require LABA as part of their asthma treatment may need to go to the hospital more frequently.<ref name=Chau2015/>
* [[Antileukotriene agents|Leukotriene receptor antagonists]] (anti-leukotriene agents such as [[montelukast]] and [[zafirlukast]]) may be used in addition to inhaled corticosteroids, typically also in conjunction with a LABA.<ref name="Antileukotriene agents" /><ref>{{cite journal | vauthors = Chauhan BF, Ducharme FM | title = Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003137 | date = January 2014 | volume = 2014 | pmid = 24459050 | doi = 10.1002/14651858.CD003137.pub5 | pmc = 10514761 | url = http://openaccess.sgul.ac.uk/2678/1/CD003137.pdf }}</ref><ref name=Cha2017>{{cite journal | vauthors = Chauhan BF, Jeyaraman MM, Singh Mann A, Lys J, Abou-Setta AM, Zarychanski R, Ducharme FM | title = Addition of anti-leukotriene agents to inhaled corticosteroids for adults and adolescents with persistent asthma | journal = The Cochrane Database of Systematic Reviews | volume = 3 | pages = CD010347 | date = March 2017 | issue = 4 | pmid = 28301050 | pmc = 6464690 | doi = 10.1002/14651858.CD010347.pub2 }}</ref><ref name="pmid22592708">{{cite journal | vauthors = Watts K, Chavasse RJ | title = Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 5 | pages = CD006100 | date = May 2012 | pmid = 22592708 | doi = 10.1002/14651858.CD006100.pub2 | veditors = Watts K | pmc = 7387678 }}</ref>  For adults or adolescents who have persistent asthma that is not controlled very well, the addition of anti-leukotriene agents along with daily inhaled corticosteriods improves lung function and reduces the risk of moderate and severe asthma exacerbations.<ref name=Cha2017/> Anti-leukotriene agents may be effective alone for adolescents and adults; however, there is no clear research suggesting which people with asthma would benefit from anti-leukotriene receptor alone.<ref>{{cite journal | vauthors = Miligkos M, Bannuru RR, Alkofide H, Kher SR, Schmid CH, Balk EM | title = Leukotriene-receptor antagonists versus placebo in the treatment of asthma in adults and adolescents: a systematic review and meta-analysis | journal = Annals of Internal Medicine | volume = 163 | issue = 10 | pages = 756–67 | date = November 2015 | pmid = 26390230 | pmc = 4648683 | doi = 10.7326/M15-1059 }}</ref>  In those under five years of age, anti-leukotriene agents were the preferred add-on therapy after inhaled corticosteroids.<ref name="BertrandSánchez2020" /><ref name=bts2009p43>{{harvnb|British Guideline|2009|p=43}}</ref> A 2013 [[Cochrane (organisation)|Cochrane]] systematic review concluded that anti-leukotriene agents appear to be of little benefit when added to inhaled steroids for treating children.<ref>{{cite journal | vauthors = Chauhan BF, Ben Salah R, Ducharme FM | title = Addition of anti-leukotriene agents to inhaled corticosteroids in children with persistent asthma | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD009585 | date = October 2013 | pmid = 24089325 | pmc = 4235447 | doi = 10.1002/14651858.CD009585.pub2 }}</ref> A similar class of drugs, [[Arachidonate 5-lipoxygenase|5-LOX]] inhibitors, may be used as an alternative in the chronic treatment of mild to moderate asthma among older children and adults.<ref name="Antileukotriene agents" /><ref name="USFDA Zileuton">{{cite web|title=Zyflo (Zileuton tablets)|url=http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020471s017lbl.pdf|website=United States Food and Drug Administration|publisher=Cornerstone Therapeutics Inc.|access-date=December 12, 2014|pages = 1|date=June 2012|url-status=live|archive-url=https://web.archive.org/web/20141213015155/http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020471s017lbl.pdf|archive-date=December 13, 2014}}</ref> {{As of|2013}} there is one medication in this family known as [[zileuton]].<ref name="Antileukotriene agents" />
* [[Mast cell stabilizer]]s (such as [[cromolyn sodium]]) are safe alternatives to corticosteroids but not preferred because they have to be administered frequently.<ref name=NHLBI07p213/><ref name="Antileukotriene agents" />
* Oral [[theophylline]]s are sometimes used for controlling chronic asthma, but their used is minimized due to side effects.<ref name="BertrandSánchez2020" />
* [[Omalizumab]], a monoclonal antibody against IgE, is a novel way to lessen exacerbations by decreasing the levels of circulating IgE that play a significant role at allergic asthma.<ref name="BertrandSánchez2020" /><ref name="Solèr ">{{cite journal | vauthors = Solèr M | title = Omalizumab, a monoclonal antibody against IgE for the treatment of allergic diseases | journal = International Journal of Clinical Practice | volume = 55 | issue = 7 | pages = 480–483 | date = September 2001 | pmid = 11594260 | doi =  10.1111/j.1742-1241.2001.tb11095.x| s2cid = 41311909 | access-date =  }}</ref>
* Anticholinergic medications such as ipratropium bromide have not been shown to be beneficial for treating chronic asthma in children over 2 years old,<ref>{{cite journal | vauthors = McDonald NJ, Bara AI | title = Anticholinergic therapy for chronic asthma in children over two years of age | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD003535 |year = 2003 | volume = 2014 | pmid = 12917970 | doi = 10.1002/14651858.CD003535 | pmc = 8717339 }}</ref> and are not suggested for routine treatment of chronic asthma in adults.<ref>{{cite journal | vauthors = Westby M, Benson M, Gibson P | title = Anticholinergic agents for chronic asthma in adults | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD003269 |year = 2004 | volume = 2017 | pmid = 15266477 | pmc = 6483359 | doi = 10.1002/14651858.CD003269.pub2 }}</ref>
* There is no strong evidence to recommend [[chloroquine]] medication as a replacement for taking corticosteroids by mouth (for those who are not able to tolerate inhaled steroids).<ref>{{cite journal | vauthors = Dean T, Dewey A, Bara A, Lasserson TJ, Walters EH | title = Chloroquine as a steroid sparing agent for asthma | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD003275 |year = 2003 | pmid = 14583965 | doi = 10.1002/14651858.CD003275 }}</ref> [[Methotrexate]] is not suggested as a replacement for taking corticosteriods by mouth ("steroid-sparing") due to the adverse effects associated with taking methotrexate and the minimal relief provided for asthma symptoms.<ref>{{cite journal | vauthors = Davies H, Olson L, Gibson P | title = Methotrexate as a steroid sparing agent for asthma in adults | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD000391 |year = 2000 | volume = 1998 | pmid = 10796540 | pmc = 6483672 | doi = 10.1002/14651858.CD000391 }}</ref>
* [[Macrolide]] antibiotics, particularly the azalide macrolide [[azithromycin]], are a recently added [[Global Initiative for Asthma]] (GINA)-recommended treatment option for both eosinophilic and non-eosinophilic severe, refractory asthma based on azithromycin's efficacy in reducing moderate and severe exacerbations combined.<ref>{{cite journal | vauthors = Hiles SA, McDonald VM, Guilhermino M, Brusselle GG, Gibson PG | title = Does maintenance azithromycin reduce asthma exacerbations? An individual participant data meta-analysis | journal = The European Respiratory Journal | volume = 54 | issue = 5 | date = November 2019 | pmid = 31515407 | doi = 10.1183/13993003.01381-2019 | s2cid = 202567597 | doi-access = free }}</ref><ref>{{cite web |last1=GINA |title=Difficult-to-Treat and Severe Asthma in Adolescent and Adult Patients: Diagnosis and Management |url=https://ginasthma.org/severeasthma/ |website=Global Initiative for Asthma |access-date=August 1, 2021}}</ref> Azithromycin's mechanism of action is not established, and could involve  pathogen- and/or host-directed anti-inflammatory activities.<ref>{{cite journal | vauthors = Steel HC, Theron AJ, Cockeran R, Anderson R, Feldman C | title = Pathogen- and host-directed anti-inflammatory activities of macrolide antibiotics | journal = Mediators of Inflammation | volume = 2012 | pages = 584262 |year = 2012 | pmid = 22778497 | pmc = 3388425 | doi = 10.1155/2012/584262 | doi-access = free }}</ref> Limited clinical observations suggest that some patients with new-onset asthma and with "difficult-to-treat" asthma (including those with the asthma-COPD overlap syndrome – ACOS) may respond dramatically to azithromycin.<ref>{{cite journal | vauthors = Hahn DL | title = When guideline treatment of asthma fails, consider a macrolide antibiotic | journal = The Journal of Family Practice | volume = 68 | issue = 10 | pages = 536;540;542;545 | date = December 2019 | pmid = 31860697 }}</ref><ref name="Outcomes of Antibiotics in Adults w" /> However, these groups of asthma patients have not been studied in randomized treatment trials and patient selection needs to be carefully individualized.
* A 2024 study indicates that commonly used diabetes medications may lower asthma attacks by up to 70%.<ref>{{Cite journal |last1=Lee |first1=Bohee |last2=Man |first2=Kenneth K. C. |last3=Wong |first3=Ernie |last4=Tan |first4=Tricia |last5=Sheikh |first5=Aziz |last6=Bloom |first6=Chloe I. |date=2024-11-18 |title=Antidiabetic Medication and Asthma Attacks |url=https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2826086?&utm_source=BulletinHealthCare&utm_medium=email&utm_term=111924&utm_content=NON-MEMBER&utm_campaign=article_alert-morning_rounds_daily&utm_uid=5590102 |journal=JAMA Internal Medicine |volume=185 |issue=1 |pages=16–25 |doi=10.1001/jamainternmed.2024.5982 |pmid=39556360 |pmc=11574725 |pmc-embargo-date=November 18, 2025 |issn=2168-6106}}</ref> The research examined [[metformin]] and GLP-1 drugs such as Ozempic ([[semaglutide]]), Mounjaro ([[tirzepatide]]), and Saxenda ([[liraglutide]]). Among nearly 13,000 participants with both diabetes and asthma, metformin reduced the risk of asthma attacks by 30%, with an additional 40% reduction when combined with a [[GLP-1 drug]].<ref>{{Cite web |last=Mundell |first=Ernie |date=2024-11-18 |title=Diabetes Meds Metformin, GLP-1s Can Also Curb Asthma |url=https://www.healthday.com/health-news/asthma/diabetes-meds-metformin-glp-1s-can-also-curb-asthma |access-date=2024-11-20 |website=www.healthday.com |language=en}}</ref>

For children with asthma which is well-controlled on combination therapy of [[inhaled corticosteroids]] (ICS) and long-acting beta<sub>2</sub>-agonists (LABA), the benefits and harms of stopping LABA and stepping down to ICS-only therapy are uncertain.<ref>{{cite journal | vauthors = Kew KM, Beggs S, Ahmad S | title = Stopping long-acting beta2-agonists (LABA) for children with asthma well controlled on LABA and inhaled corticosteroids | journal = The Cochrane Database of Systematic Reviews | issue = 5 | pages = CD011316 | date = May 2015 | volume = 2017 | pmid = 25997166 | pmc = 6486153 | doi = 10.1002/14651858.CD011316.pub2 | url = http://ecite.utas.edu.au/108910 }}</ref> In adults who have stable asthma while they are taking a combination of LABA and inhaled corticosteroids (ICS), stopping LABA may increase the risk of asthma exacerbations that require treatment with corticosteroids by mouth.<ref name=Ahm2015>{{cite journal | vauthors = Ahmad S, Kew KM, Normansell R | title = Stopping long-acting beta2-agonists (LABA) for adults with asthma well controlled by LABA and inhaled corticosteroids | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD011306 | date = June 2015 | volume = 2015 | pmid = 26089258 | doi = 10.1002/14651858.CD011306.pub2 | pmc = 11114094 | url = http://openaccess.sgul.ac.uk/107422/1/CD011306.pdf }}</ref> Stopping LABA probably makes little or no important difference to asthma control or asthma-related quality of life.<ref name=Ahm2015/> Whether or not stopping LABA increases the risk of serious adverse events or exacerbations requiring an emergency department visit or hospitalization is uncertain.<ref name=Ahm2015/>

====Delivery methods====
Medications are typically provided as [[metered-dose inhaler]]s (MDIs) in combination with an [[inhaler spacer]] or as a [[dry powder inhaler]]. The spacer is a plastic cylinder that mixes the medication with air, making it easier to receive a full dose of the drug. A [[nebulizer]] may also be used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms. However, insufficient evidence is available to determine whether a difference exists in those with severe disease.<ref name="NHLBI07p250">{{harvnb|NHLBI Guideline|2007|p=250}}</ref> For delivering short-acting beta-agonists in acute asthma in children, spacers may have advantages compared to nebulisers, but children with life-threatening asthma have not been studied.<ref>{{cite journal | vauthors = Cates CJ, Welsh EJ, Rowe BH | title = Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD000052 | date = September 2013 | volume = 2013 | pmid = 24037768 | doi = 10.1002/14651858.CD000052.pub3 | pmc = 7032675 |collaboration = Cochrane Airways Group }}</ref> There is no strong evidence for the use of intravenous LABA for adults or children who have acute asthma.<ref>{{cite journal | vauthors = Travers AH, Milan SJ, Jones AP, Camargo CA, Rowe BH | title = Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | pages = CD010179 | date = December 2012 | issue = 12 | pmid = 23235685 | doi = 10.1002/14651858.CD010179 | pmc = 11289706 }}</ref> There is insufficient evidence to directly compare the effectiveness of a metered-dose inhaler attached to a homemade spacer compared to commercially available spacer for treating children with asthma.<ref>{{cite journal | vauthors = Rodriguez C, Sossa M, Lozano JM | title = Commercial versus home-made spacers in delivering bronchodilator therapy for acute therapy in children | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD005536 | date = April 2008 | volume = 2017 | pmid = 18425921 | pmc = 6483735 | doi = 10.1002/14651858.CD005536.pub2 }}</ref>

====Adverse effects====
Long-term use of inhaled corticosteroids at conventional doses carries a minor risk of adverse effects.<ref name=Safe09>{{cite journal | vauthors = Rachelefsky G | title = Inhaled corticosteroids and asthma control in children: assessing impairment and risk | journal = Pediatrics | volume = 123 | issue = 1 | pages = 353–66 | date = January 2009 | pmid = 19117903 | doi = 10.1542/peds.2007-3273 | s2cid = 22386752 }}</ref> Risks include [[oral candidiasis|thrush]], the development of [[cataract]]s, and a slightly slowed rate of growth.<ref name=Safe09/><ref>{{cite journal | vauthors = Dahl R | title = Systemic side effects of inhaled corticosteroids in patients with asthma | journal = Respiratory Medicine | volume = 100 | issue = 8 | pages = 1307–17 | date = August 2006 | pmid = 16412623 | doi = 10.1016/j.rmed.2005.11.020 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Thomas MS, Parolia A, Kundabala M, Vikram M | title = Asthma and oral health: a review | journal = Australian Dental Journal | volume = 55 | issue = 2 | pages = 128–33 | date = June 2010 | pmid = 20604752 | doi = 10.1111/j.1834-7819.2010.01226.x | doi-access =  }}</ref> Rinsing the mouth after the use of inhaled steroids can decrease the risk of thrush.<ref>{{cite book | vauthors = Domino FJ, Baldor RA, Golding J, Grimes JA |title=The 5-Minute Clinical Consult Premium 2015 |date=2014 |publisher=Lippincott Williams & Wilkins |isbn=978-1-4511-9215-5 |page=192 |url=https://books.google.com/books?id=T-XtAwAAQBAJ&pg=PA192 }}</ref> Higher doses of inhaled steroids may result in lower [[bone mineral density]].<ref>{{cite journal |vauthors=Skoner DP |title=Inhaled corticosteroids: Effects on growth and bone health |journal=Annals of Allergy, Asthma & Immunology |volume=117 |issue=6 |pages=595–600 |date=December 2016 |pmid=27979015 |doi=10.1016/j.anai.2016.07.043 }}</ref>

===Others===
Inflammation in the lungs can be estimated by the level of exhaled [[nitric oxide]].<ref name="Petsky_2016" /><ref name="Petsky_2016_2" /> The use of exhaled nitric oxide levels (FeNO) to guide asthma medication dosing may have small benefits for preventing asthma attacks but the potential benefits are not strong enough for this approach to be universally recommended as a method to guide asthma therapy in adults or children.<ref name="Petsky_2016">{{cite journal | vauthors = Petsky HL, Kew KM, Turner C, Chang AB | title = Exhaled nitric oxide levels to guide treatment for adults with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD011440 | date = September 2016 | issue = 9 | pmid = 27580628 | pmc = 6457753 | doi = 10.1002/14651858.CD011440.pub2 }}</ref><ref name="Petsky_2016_2">{{cite journal | vauthors = Petsky HL, Kew KM, Chang AB | title = Exhaled nitric oxide levels to guide treatment for children with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 11 | pages = CD011439 | date = November 2016 | issue = 5 | pmid = 27825189 | pmc = 6432844 | doi = 10.1002/14651858.CD011439.pub2 }}</ref>

When asthma is unresponsive to usual medications, other options are available for both emergency management and prevention of flareups. Additional options include:
* Humidified [[oxygen]] to alleviate [[hypoxia (medical)|hypoxia]] if [[oxygen saturation|saturations]] fall below 92%.<ref name="BertrandSánchez2020" />
* Corticosteroids by mouth, with five days of [[prednisone]] being the same two days of [[dexamethasone]].<ref>{{cite journal | vauthors = Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL | display-authors = 6 | title = Dexamethasone for acute asthma exacerbations in children: a meta-analysis | journal = Pediatrics | volume = 133 | issue = 3 | pages = 493–9 | date = March 2014 | pmid = 24515516 | pmc = 3934336 | doi = 10.1542/peds.2013-2273 }}</ref> One review recommended a seven-day course of steroids.<ref>{{cite journal | vauthors = Rowe BH, Kirkland SW, Vandermeer B, Campbell S, Newton A, Ducharme FM, Villa-Roel C | s2cid = 30182169 | title = Prioritizing Systemic Corticosteroid Treatments to Mitigate Relapse in Adults With Acute Asthma: A Systematic Review and Network Meta-analysis | journal = Academic Emergency Medicine | volume = 24 | issue = 3 | pages = 371–381 | date = March 2017 | pmid = 27664401 | doi = 10.1111/acem.13107 | doi-access = free }}</ref>
* [[Magnesium sulfate]] intravenous treatment increases bronchodilation when used in addition to other treatment in moderate severe acute asthma attacks.<ref name="NHLBI07p373" /><ref>{{cite journal | vauthors = Noppen M | title = Magnesium treatment for asthma: where do we stand? | journal = Chest | volume = 122 | issue = 2 | pages = 396–8 | date = August 2002 | pmid = 12171805 | doi = 10.1378/chest.122.2.396 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Griffiths B, Kew KM | title = Intravenous magnesium sulfate for treating children with acute asthma in the emergency department | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD011050 | date = April 2016 | issue = 4 | pmid = 27126744 | pmc = 6599814 | doi = 10.1002/14651858.CD011050.pub2 | url = http://openaccess.sgul.ac.uk/107920/1/MCG%2DAST.pdf }}</ref> In adults intravenous treatment results in a reduction of hospital admissions.<ref>{{cite journal | vauthors = Kew KM, Kirtchuk L, Michell CI | title = Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department | journal = The Cochrane Database of Systematic Reviews | volume = 5 | issue = 5 | pages = CD010909 | date = May 2014 | pmid = 24865567 | doi = 10.1002/14651858.CD010909.pub2 | pmc = 10892514 | url = http://openaccess.sgul.ac.uk/107426/1/CD010909.pdf | veditors = Kew KM }}</ref> Low levels of evidence suggest that inhaled (nebulized) magnesium sulfate may have a small benefit for treating acute asthma in adults.<ref name="Knightly_2017">{{cite journal | vauthors = Knightly R, Milan SJ, Hughes R, Knopp-Sihota JA, Rowe BH, Normansell R, Powell C | title = Inhaled magnesium sulfate in the treatment of acute asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | pages = CD003898 | date = November 2017 | issue = 11 | pmid = 29182799 | pmc = 6485984 | doi = 10.1002/14651858.CD003898.pub6 }}</ref> Overall, high-quality evidence do not indicate a large benefit for combining magnesium sulfate with standard inhaled treatments for adults with asthma.<ref name="Knightly_2017" />
* [[Heliox]], a mixture of helium and oxygen, may also be considered in severe unresponsive cases.<ref name="NHLBI07p373" />
* Intravenous salbutamol is not supported by available evidence and is thus used only in extreme cases.<ref name=rodrigo>{{cite journal | vauthors = Rodrigo GJ, Rodrigo C, Hall JB | title = Acute asthma in adults: a review | journal = Chest | volume = 125 | issue = 3 | pages = 1081–102 | date = March 2004 | pmid = 15006973 | doi = 10.1378/chest.125.3.1081 }}</ref>
* [[Methylxanthines]] (such as [[theophylline]]) were once widely used, but do not add significantly to the effects of inhaled beta-agonists.<ref name=rodrigo/> Their use in acute exacerbations is controversial.<ref name="GINA_2011_page37">{{harvnb|GINA|2011|p=37}}</ref>
* The dissociative anaesthetic [[ketamine]] is theoretically useful if [[intubation]] and [[mechanical ventilation]] is needed in people who are approaching respiratory arrest; however, there is no evidence from clinical trials to support this.<ref name="NHLBI07p399">{{harvnb|NHLBI Guideline|2007|p=399}}</ref>  A 2012 Cochrane review found no significant benefit from the use of ketamine in severe acute asthma in children.<ref>{{cite journal | vauthors = Jat KR, Chawla D | title = Ketamine for management of acute exacerbations of asthma in children | journal = The Cochrane Database of Systematic Reviews | volume = 11 | issue = 11 | pages = CD009293 | date = November 2012 | pmid = 23152273 | pmc = 6483733 | doi = 10.1002/14651858.CD009293.pub2 | collaboration = Cochrane Airways Group }}</ref>
* For those with severe persistent asthma not controlled by inhaled corticosteroids and LABAs, [[bronchial thermoplasty]] may be an option.<ref name=Bronch10>{{cite journal | vauthors = Castro M, Musani AI, Mayse ML, Shargill NS | title = Bronchial thermoplasty: a novel technique in the treatment of severe asthma | journal = Therapeutic Advances in Respiratory Disease | volume = 4 | issue = 2 | pages = 101–16 | date = April 2010 | pmid = 20435668 | doi = 10.1177/1753465810367505 | doi-access = free }}</ref> It involves the delivery of controlled thermal energy to the airway wall during a series of [[bronchoscopy|bronchoscopies]].<ref name=Bronch10/><ref>{{cite journal | vauthors = Boulet LP, Laviolette M | title = Is there a role for bronchial thermoplasty in the treatment of asthma? | journal = Canadian Respiratory Journal | volume = 19 | issue = 3 | pages = 191–2 | date = May–Jun 2012 | pmid = 22679610 | pmc = 3418092 | doi = 10.1155/2012/853731 | doi-access = free }}</ref> While it may increase exacerbation frequency in the first few months it appears to decrease the subsequent rate.<!-- <ref name=GINA_2011_page70> --> Effects beyond one year are unknown.<ref name=GINA_2011_page70>{{harvnb|GINA|2011|p=70}}</ref>
* [[Monoclonal antibody]] injections such as [[mepolizumab]],<ref name="Mepolizumab">{{cite web|url=https://www.fda.gov/media/114447/download |title=Pulmonary-Allergy Drugs Advisory Committee Meeting|date=July 25, 2018|publisher=[[FDA]]|access-date=May 9, 2019}}</ref> [[dupilumab]],<ref name="Dupilumab">{{cite journal | vauthors = Sastre J, Dávila I | title = Dupilumab: A New Paradigm for the Treatment of Allergic Diseases | journal = Journal of Investigational Allergology & Clinical Immunology | volume = 28 | issue = 3 | pages = 139–150 | date = June 2018 | pmid = 29939132 | doi = 10.18176/jiaci.0254 | doi-access = free | hdl = 10486/686799 | hdl-access = free }}</ref> or [[omalizumab]] may be useful in those with poorly controlled atopic asthma.<ref name=NEJM2017>{{cite journal | vauthors = Israel E, Reddel HK | title = Severe and Difficult-to-Treat Asthma in Adults | journal = The New England Journal of Medicine | volume = 377 | issue = 10 | pages = 965–976 | date = September 2017 | pmid = 28877019 | doi = 10.1056/NEJMra1608969 | s2cid = 44767865 }}</ref> However, {{As of|2019|lc=y}} these medications are expensive and their use is therefore reserved for those with severe symptoms to achieve cost-effectiveness.<ref>{{cite journal | vauthors = McQueen RB, Sheehan DN, Whittington MD, van Boven JF, Campbell JD | title = Cost-Effectiveness of Biological Asthma Treatments: A Systematic Review and Recommendations for Future Economic Evaluations | journal = PharmacoEconomics | volume = 36 | issue = 8 | pages = 957–971 | date = August 2018 | pmid = 29736895 | doi = 10.1007/s40273-018-0658-x | s2cid = 13681118 }}</ref> Monoclonal antibodies targeting [[Interleukin 5|interleukin-5]] (IL-5) or its receptor (IL-5R), including [[mepolizumab]], [[reslizumab]] or [[benralizumab]], in addition to standard care in severe asthma is effective in reducing the rate of asthma exacerbations. There is limited evidence for improved health-related quality of life and lung function.<ref>{{cite journal | vauthors = Farne HA, Wilson A, Milan S, Banchoff E, Yang F, Powell CV | title = Anti-IL-5 therapies for asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 7 | pages = CD010834 | date = July 2022 | pmid = 35838542 | pmc = 9285134 | doi = 10.1002/14651858.CD010834.pub4 }}</ref>
* Evidence suggests that [[sublingual immunotherapy]] in those with both [[allergic rhinitis]] and asthma improve outcomes.<ref name="pmid23532243">{{cite journal | vauthors = Lin SY, Erekosima N, Kim JM, Ramanathan M, Suarez-Cuervo C, Chelladurai Y, Ward D, Segal JB | display-authors = 6 | title = Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review | journal = JAMA | volume = 309 | issue = 12 | pages = 1278–88 | date = March 2013 | pmid = 23532243 | doi = 10.1001/jama.2013.2049 | doi-access =  }}</ref>
* It is unclear if [[non-invasive positive pressure ventilation]] in children is of use as it has not been sufficiently studied.<ref>{{cite journal | vauthors = Korang SK, Feinberg J, Wetterslev J, Jakobsen JC | title = Non-invasive positive pressure ventilation for acute asthma in children | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD012067 | date = September 2016 | issue = 9 | pmid = 27687114 | pmc = 6457810 | doi = 10.1002/14651858.CD012067.pub2 }}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/39356050|date = October 2024}}

=== Adherence to asthma treatments ===
Staying with a treatment approach for preventing asthma exacerbations can be challenging, especially if the person is required to take medicine or treatments daily.<ref name="Chan_2022">{{cite journal | vauthors = Chan A, De Simoni A, Wileman V, Holliday L, Newby CJ, Chisari C, Ali S, Zhu N, Padakanti P, Pinprachanan V, Ting V, Griffiths CJ | display-authors = 6 | title = Digital interventions to improve adherence to maintenance medication in asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 6 | pages = CD013030 | date = June 2022 | pmid = 35691614 | pmc = 9188849 | doi = 10.1002/14651858.CD013030.pub2 | collaboration = Cochrane Airways Group }}</ref> Reasons for low [[Adherence (medicine)|adherence]] range from a conscious decision to not follow the suggested medical treatment regime for various reasons including avoiding potential [[side effect]]s, [[Medical misinformation|misinformation]], or other beliefs about the medication.<ref name="Chan_2022" /> Problems accessing the treatment and problems administering the treatment effectively can also result in lower adherence. Various approaches have been undertaken to try and improve adherence to treatments to help people prevent serious asthma exacerbations including digital interventions.<ref name="Chan_2022" />

===Alternative medicine===
Many people with asthma, like those with other chronic disorders, use [[Alternative medicine|alternative treatments]]; surveys show that roughly 50% use some form of unconventional therapy.<ref name="blanc">{{cite journal | vauthors = Blanc PD, Trupin L, Earnest G, Katz PP, Yelin EH, Eisner MD | title = Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis : data from a population-based survey | journal = Chest | volume = 120 | issue = 5 | pages = 1461–7 | date = November 2001 | pmid = 11713120 | doi = 10.1378/chest.120.5.1461 }}</ref><ref name=shenfield>{{cite journal | vauthors = Shenfield G, Lim E, Allen H | title = Survey of the use of complementary medicines and therapies in children with asthma | journal = Journal of Paediatrics and Child Health | volume = 38 | issue = 3 | pages = 252–7 | date = June 2002 | pmid = 12047692 | doi = 10.1046/j.1440-1754.2002.00770.x | s2cid = 22129160 }}</ref> There is little data to support the effectiveness of most of these therapies.

Evidence is insufficient to support the usage of [[vitamin C]] or [[vitamin E]] for controlling asthma.<ref>{{cite journal | vauthors = Milan SJ, Hart A, Wilkinson M | title = Vitamin C for asthma and exercise-induced bronchoconstriction | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD010391 | date = October 2013 | volume = 2013 | pmid = 24154977 | pmc = 6513466 | doi = 10.1002/14651858.CD010391.pub2 }}</ref><ref>{{cite journal | vauthors = Wilkinson M, Hart A, Milan SJ, Sugumar K | title = Vitamins C and E for asthma and exercise-induced bronchoconstriction | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD010749 | date = June 2014 | volume = 2014 | pmid = 24936673 | pmc = 6513032 | doi = 10.1002/14651858.CD010749.pub2 }}</ref> There is tentative support for use of vitamin C in exercise induced bronchospasm.<ref>{{cite journal | vauthors = Hemilä H | title = Vitamin C may alleviate exercise-induced bronchoconstriction: a meta-analysis | journal = BMJ Open | volume = 3 | issue = 6 | pages = e002416 | date = June 2013 | pmid = 23794586 | pmc = 3686214 | doi = 10.1136/bmjopen-2012-002416 }} {{open access}}</ref> [[Fish oil]] dietary supplements (marine n-3 fatty acids)<ref>{{cite journal | vauthors = Woods RK, Thien FC, Abramson MJ | title = Dietary marine fatty acids (fish oil) for asthma in adults and children | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 3 | pages = CD001283 |year = 2002 | pmid = 12137622 | pmc = 6436486 | doi = 10.1002/14651858.CD001283 }}</ref> and reducing dietary sodium<ref>{{cite journal | vauthors = Pogson Z, McKeever T | title = Dietary sodium manipulation and asthma | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD000436 | date = March 2011 | volume = 2011 | pmid = 21412865 | doi = 10.1002/14651858.CD000436.pub3 | pmc = 7032646 }}</ref> do not appear to help improve asthma control. In people with mild to moderate asthma, treatment with [[vitamin D]] supplementation or its hydroxylated metabolites does not reduce acute exacerbations or improve control.<ref name="Williamson_2023">{{cite journal | vauthors = Williamson A, Martineau AR, Sheikh A, Jolliffe D, Griffiths CJ | title = Vitamin D for the management of asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2023 | issue = 2 | pages = CD011511 | date = February 2023 | pmid = 36744416 | pmc = 9899558 | doi = 10.1002/14651858.CD011511.pub3 }}</ref> There is no strong evidence to suggest that vitamin D supplements improve day-to-day asthma symptoms or a person's lung function.<ref name="Williamson_2023" /> There is no strong evidence to suggest that adults with asthma should avoid foods that contain [[monosodium glutamate]] (MSG).<ref name="Zhou_2012">{{cite journal | vauthors = Zhou Y, Yang M, Dong BR | title = Monosodium glutamate avoidance for chronic asthma in adults and children | journal = The Cochrane Database of Systematic Reviews | issue = 6 | pages = CD004357 | date = June 2012 | volume = 2014 | pmid = 22696342 | doi = 10.1002/14651858.CD004357.pub4 | pmc = 8823518 }}</ref> There have not been enough high-quality studies performed to determine if children with asthma should avoid eating food that contains MSG.<ref name="Zhou_2012" />

[[Acupuncture]] is not recommended for the treatment as there is insufficient evidence to support its use.<ref name="NHLBI07p240" /><ref name="mccartney">{{cite journal | vauthors = McCarney RW, Brinkhaus B, Lasserson TJ, Linde K | title = Acupuncture for chronic asthma | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD000008 |year=2004 | volume = 2009 | pmid = 14973944 | doi = 10.1002/14651858.CD000008.pub2 | veditors = McCarney RW | pmc = 7061358 }}</ref> [[Air ionizer]]s show no evidence that they improve asthma symptoms or benefit lung function; this applied equally to positive and negative ion generators.<ref name="pmid22972060">{{cite journal | vauthors = Blackhall K, Appleton S, Cates CJ | title = Ionisers for chronic asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 9 | pages = CD002986 | date = September 2012 | pmid = 22972060 | pmc = 6483773 | doi = 10.1002/14651858.CD002986.pub2 | veditors = Blackhall K }}</ref> Manual therapies, including [[osteopathy|osteopathic]], [[chiropractic]], [[physical therapy|physiotherapeutic]] and [[respiratory therapy|respiratory therapeutic]] manoeuvres, have insufficient evidence to support their use in treating asthma.<ref name="hondras">{{cite journal | vauthors = Hondras MA, Linde K, Jones AP | title = Manual therapy for asthma | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD001002 | date = April 2005 | pmid = 15846609 | doi = 10.1002/14651858.CD001002.pub2 | veditors = Hondras MA }}</ref>  Pulmonary rehabilitation, however, may improve quality of life and functional exercise capacity when compared to usual care for adults with asthma.<ref>{{cite journal | vauthors = Osadnik CR, Gleeson C, McDonald VM, Holland AE | title = Pulmonary rehabilitation versus usual care for adults with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 8 | pages = CD013485 | date = August 2022 | pmid = 35993916 | pmc = 9394585 | doi = 10.1002/14651858.CD013485.pub2 | collaboration = Cochrane Airways Group }}</ref> The [[Buteyko breathing technique]] for controlling hyperventilation may result in a reduction in medication use; however, the technique does not have any effect on lung function.<ref name="BGMA08" />  Thus an expert panel felt that evidence was insufficient to support its use.<ref name="NHLBI07p240">{{harvnb|NHLBI Guideline|2007|p=240}}</ref> There is no clear evidence that breathing exercises are effective for treating children with asthma.<ref>{{cite journal | vauthors = Macêdo TM, Freitas DA, Chaves GS, Holloway EA, Mendonça KM | title = Breathing exercises for children with asthma | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | pages = CD011017 | date = April 2016 | issue = 4 | pmid = 27070225 | doi = 10.1002/14651858.CD011017.pub2 | pmc = 7104663 }}</ref>