Initial treatment of allergic rhinitis (AR) depends on the severity of symptoms and whether they are intermittent or persistent (see Table 1).

View the Comparison Table: Some Nasal Sprays for Seasonal Allergic Rhinitis

The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations in the emergency department is not discussed here.

View the Comparison Chart: Some Inhaled Drugs for Treatment of Asthma

View the Comparison Table: Some Oral Drugs for Allergic Rhinitis

View the Comparison Table: Some Nasal Sprays for Allergic Rhinitis

The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations of asthma in the emergency department is not discussed here.

View the table: Some Inhaled Drugs for Treatment of Asthma

View the Table: Correct Use of Inhalers for COPD

INHALATION DEVICES — Metered-dose inhalers (MDIs) require coordination of inhalation with hand-actuation of the device. Valved holding chambers (VHCs) or spacers help some patients, especially young children and the elderly, use MDIs effectively. VHCs have one-way valves that prevent the patient from exhaling into the device, minimizing the need for coordinated actuation and inhalation. Spacers are tubes or chambers placed between the canister and a face mask or mouthpiece, which also avoids the need to coordinate actuation and inhalation. Both VHCs and spacers retain the larger particles emitted from the MDI, decreasing their deposition in the oropharynx and leading to a higher proportion of small respirable particles being inhaled.

The FDA has approved a nasal spray fixed-dose combination (Dymista – Meda) of the H₁-antihistamine azelastine (Astelin, Astepro, and generics) and the corticosteroid fluticasone propionate (Flonase, and generics) for treatment of seasonal allergic rhinitis (SAR) in patients ≥12 years old who need both medications for symptomatic relief. It is the first nasal spray to be approved in the US that contains both an H₁-antihistamine and a corticosteroid.

The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and decrease complications of the disease such as acute exacerbations. Other guidelines for treatment of this condition have been published or updated in recent years.

Allergic rhinitis, allergic conjunctivitis, atopic dermatitis, urticaria, anaphylaxis and asthma (not included here; reviewed in Treatment Guidelines 2008; 6:83) are prevalent worldwide, especially in industrialized countries. Pharmacologic treatment of these disorders continues to improve in efficacy and safety. In addition to using drugs to prevent and control these allergic diseases, patients should be instructed to avoid, if possible, specific allergens and/or environmental conditions that trigger or worsen their symptoms. Allergen-specific immunotherapy may be useful for treatment of allergic rhinitis and allergic conjunctivitis, and in preventing severe insect venom-triggered reactions.

No truly new drugs have been approved for treatment of asthma since omalizumab (Xolair) in 2003, but some randomized controlled trials of older drugs have been published, and new guidelines have become available.

The FDA has approved the marketing of the corticosteroid ciclesonide (Alvesco - Sepracor) in a hydrofluoroalkane (HFA) metered-dose inhaler formulation for maintenance treatment of asthma in patients >12 years old. Ciclesonide is also available in the US as a nasal spray for allergic rhinitis (Omnaris), and has been available for asthma in Europe since 2003.

Ciclesonide (Omnaris - Sepracor/Nycomed), a once daily corticosteroid nasal spray, is now available for treatment of seasonal allergic rhinitis (SAR) in adults and children ≥6 years old and for perennial allergic rhinitis (PAR) in those ≥12 years old. An orally inhaled formulation of ciclesonide (Alvesco) was recently approved by the FDA for maintenance treatment of asthma, and will be reviewed in a future issue of The Medical Letter

The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and minimize complications of the disease such as acute exacerbations and cor pulmonale. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines developed by the World Health Organization and the National Heart, Lung and Blood Institute were updated in 2006. The American Thoracic Society and the European Respiratory Society jointly developed guidelines for COPD in 2004.

The FDA has approved marketing of the corticosteroid mometasone furoate in an orally inhaled dry powder formulation (Asmanex Twisthaler - Schering-Plough) for maintenance treatment of asthma in patients at least 12 years old. Mometasone is also available as a mid-potency topical corticosteroid cream (Elocon) and as an intranasal spray (Nasonex) for treatment of allergic rhinitis.

Patients with mild, infrequent asthma symptoms may require only intermittent, asneeded use of an inhaled short-acting beta2-adrenergic agonist. Use of a short-acting beta2-agonist more than twice weekly, other than for exercise-induced bronchospasm, indicates a need for anti-inflammatory treatment. Inhaled corticosteroids are the most effective anti-inflammatory medication; leukotriene modifiers are less effective alternatives. If regular use of an inhaled corticosteroid in a low dose does not prevent symptoms, a long-acting beta2-agonist should be added; addition of a second drug is more effective than raising the dose of the inhaled steroid. A leukotriene modifier can also be used as the second drug. Omalizumab may be considered as adjunctive therapy for patients more than 12 years old who have allergic asthma not controlled by other drugs. A short course of oral corticosteroids may be useful for acute exacerbations. Treatment of acute severe asthma as a medical emergency is not included here; it has been reviewed elsewhere (ER McFadden Jr, Am J Respir Crit Care Med 2003; 168:740).

New drug formulations continue to be introduced for the treatment of asthma, and new studies on older drugs continue to change our perspectives on the management of this chronic inflammatory disease. Treatment of asthma in the emergency department or hospital is not addressed here. More information on the diagnosis and treatment of asthma is available from Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda:NIH, 1997 and 2002 update; www.nhlbi.nih.gov).

Fluticasone propionate, an inhaled corticosteroid, and salmeterol xinafoate, a long-acting beta2-adrenergic agonist, are now available together in a dry-powder inhaler for maintenance treatment of patients with asthma. The new combination is not recommended for treatment of acute bronchospasm or for treatment of children less than 12 years old.

The FDA has approved a nebulized suspension of the corticosteroid budesonide for maintenance treatment of persistent asthma in children one to eight years old.

Asthma is a chronic inflammatory disorder of the airways; inflammation caused by allergens, viral respiratory infections or other stimuli leads to bronchial hyperresponsiveness and obstruction of airflow. Anti-inflammatory drugs, particularly inhaled corticosteroids, are central to its management.

An intranasal spray formulation of the topical corticosteroid mometasone furoate, marketed for treatment of seasonal and perennial allergic rhinitis, has been advertised on television directly to the public.

Asthma is a chronic inflammatory disorder, with inflammation caused by allergens or other stimuli leading to bronchial hyperresponsiveness and obstruction of airflow.

Montelukast sodium (Singulair - Merck), a leukotriene receptor antagonist, has been approved by the US Food and Drug Administration (FDA) for oral prophylaxis and chronic treatment of asthma in adults and children at least 6 years old. It is the third 'leukotriene modifier' to become available in the USA; zafirlukast (Accolate - Medical Letter, 38:111, 1996) and zileuton (Zyflo - Medical Letter, 39:18, 1997) were marketed previously. Neither zafirlukast nor zileuton has been approved by the FDA for use in children less than 12 years old. Leukotriene modifiers are not recommended for treatment of an acute asthma attack (Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma, Bethesda: NIH, 1997; www.nhlbi.NIH.gov/nhlbi/lung/ asthma/prof/asthgdln.htm).

The FDA has approved marketing of the corticosteroid budesonide in an oral inhalatoin powder formulation (Pulmicort Turbuhaler - Astra) for maintenance treatment of asthma in adults and children at least six years old. Budesonide has been available in the USA as an intranasal spray (Rhinocort) for treatment of allergic rhinitis since 1994 and has been used for inhalation treatment of asthma in Canada and Europe for ten years.

Zafirlukast (za fir loo kast; Accolate - Zeneca), the first leukotriene receptor anta-gonist approved by the US Food and Drug Administration, is now being heavily promoted for oral maintenance treatment of chronic asthma in patients more than 12 years old. It is not recommended for treatment of acute asthma.

An inhalation aerosol formulation of the corticosteroid fluticasone propionate (Flovent -Glaxo Wellcome) has been approved by the US Food and Drug Administration for maintenance treatment of asthma.

An intranasal spray formulation of the corticosteroid fluticasone propionate (floo tik a sone; Flonase - Allen & Hanburys) has been approved by the US Food and Drug Administration for treatment of seasonal and perennial allergic rhinitis in adults and children more than 12 years old.

An intranasal formulation of the corticosteroid budesonide (Rhinocort Nasal Inhaler - Astra) was recently approved by the US Food and Drug Administration for treatment of seasonal or perennial allergic rhinitis in adults and children and nonallergic perennial rhinitis in adults. Budesonide has been available in Canada and Europe for several years for inhalation treatment of both allergic rhinitis and asthma.

Salmeterol xinafoate (Serevent - Allen & Hanburys), a long-acting β 2 -selective adrenergic agonist for inhalation, has been approved by the US Food and Drug Administration for maintenance treatment of asthma, with or without concurrent use of inhaled corticosteroids. Salmeterol is not recommended for acute treatment of bronchospasm.

Nedocromil sodium (Tilade - Fisons), an anti-inflammatory drug similar to cromolyn sodium (Intal - Fisons), although chemically unrelated, is now available in the USA as a metered-dose inhaler for maintenance treatment of mild to moderate asthma.

An intranasal formulation of the corticosteroid triamcinolone (Nasacort - Rh ne- Poulenc Rorer) was recently approved by the US Food and Drug Administration for once-daily treatment of seasonal and perennial allergic rhinitis.