Reviews and feature article
Therapeutic strategies to reduce asthma exacerbations

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Asthma exacerbations can occur in patients with all degrees of asthma severity. They generally develop over 5 to 7 days and are most often initiated by an upper respiratory tract infection (usually with human rhinovirus) or by environmental allergen exposure in atopic subjects. Inhaled corticosteroids (ICSs) taken on a regular basis are very effective in reducing the risk of asthma exacerbations, and the combination of ICSs and long-acting inhaled β2-agonists further reduces this risk. In addition, use of the combination of the ICS budesonide and the long-acting inhaled β2-agonist formoterol, both as maintenance asthma treatment and also as rescue treatment (instead of a short-acting inhaled β2-agonist), has a significant further beneficial effect on asthma exacerbation risk. Other therapies that have been demonstrated to reduce severe asthma exacerbations are leukotriene receptor antagonists, which have been demonstrated to be effective most consistently in this regard in children, and anti-IgE mAbs, which are effective in subjects with difficult-to-treat allergic asthma. Approximately 50% of severe asthma exacerbations are eosinophilic in nature, whereas many of the remaining are neutrophilic. Several studies have demonstrated that making asthma treatment decisions based on minimizing airway eosinophil numbers (measured in induced sputum) can reduce the risks of severe exacerbations. In addition, treatment of patients with severe asthma with an anti–IL-5 mAb also reduces the number of severe asthma exacerbations, demonstrating a central role of eosinophils in many exacerbations.

Section snippets

Prevention of severe asthma exacerbations

The purpose of asthma treatment is to attempt to achieve total asthma control.13, 14 Asthma control consists of 2 domains: current control (impairment), which reflects the day-to-day symptoms an asthmatic patient experiences and the burden imposed by these symptoms, and future risk, which consists of asthma exacerbations, irreversible decrease in lung function, and side effects from asthma medications.13 Thus the prevention of asthma exacerbations is an important component of establishing ideal

Conclusions

Severe asthma exacerbations can occur in any asthmatic patient and have potential long-term consequences with regard to a decrease in lung function. ISC treatment is very effective in reducing severe exacerbations when used as monotherapy, and the combination of an ICS with a LABA provides even more protection. In patients with a history of severe exacerbations, using ICS/LABA combinations, which contain the LABA formoterol, both as maintenance and rescue treatment has been shown to be superior

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