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Combination of inhaled corticosteroids plus other medications in the management of moderate to severe persistent asthma.

Severe persistent asthma accounts for a small percentage, probably less than 5% of all patients with asthma, but is responsible for the major portion of health care costs associated with the illness. According to the National Institutes of Health (National Asthma Education and Prevention Program) guidelines for the management of asthma, patients with severe asthma should be treated with high dosages of inhaled corticosteroids. These inhaled corticosteroids can be given in conjunction with a brief course of oral or parenteral systemic steroids, but it is best to decrease or eliminate systemic corticosteroid therapy whenever possible to prevent the side effects of long-term oral prednisone therapy. If inhaled corticosteroids do not control the asthma, then one or perhaps two, and even three, other long-term control medications can be added to the therapy regimen. Current guidelines recommend adding a long-acting beta 2-agonist such as salmeterol to the inhaled corticosteroid. Recent evidence suggests that leukotriene receptor antagonists can also be used in conjunction with inhaled steroids. Theophylline is also recommended as another controller agent to be considered. Unfortunately, no studies have comparatively evaluated all of these different classes of agents, even in moderate asthma, in head-to-head trials. This manuscript will review the current literature and provide the author's perspective on the combination of these medications in the pharmacologic management of moderate to severe persistent asthma.