Asthma: What Each Medicine Actually Does
Relievers open the airways for a few hours. Controllers treat the inflammation underneath. Confusing the two is the single most common and most dangerous mistake in asthma treatment.
What is Asthma?
Asthma is a long-term inflammatory condition of the airways. Two things are happening at once, and treating only one of them is where most asthma goes wrong. The first is bronchoconstriction: the smooth muscle wrapping the airways tightens, the airway narrows, and breathing becomes difficult. This is what a patient feels during an attack and what a reliever inhaler reverses within minutes. The second is inflammation: the airway lining is swollen, producing mucus, and hypersensitive to triggers. This is present between attacks, when the patient feels completely well, and it is what determines how often attacks happen and how severe they get. Relievers do nothing to it. That asymmetry explains the defining problem in asthma care. The drug that produces an immediate sensation of relief does not treat the disease, and the drug that treats the disease produces no sensation at all. Patients reliably over-use the first and under-use the second, and the pattern is strongly associated with severe attacks. Guidance changed decisively in 2019. The Global Initiative for Asthma no longer recommends short-acting reliever monotherapy at any step of treatment for adults and adolescents. Every patient with asthma should be on some form of anti-inflammatory treatment, and for mild asthma the preferred approach is now an inhaled corticosteroid combined with formoterol, used as needed, so that every rescue dose also delivers an anti-inflammatory dose. Asthma cannot currently be cured. It can be controlled well enough that most people have normal lung function, no symptom limitation on activity and no attacks, and that is the target treatment aims at rather than merely reducing symptoms.
!Symptoms
- •Wheezing, a whistling sound on breathing out, often worse at night
- •Shortness of breath, particularly on exertion or after a trigger
- •Chest tightness, described as a band or weight rather than pain
- •Persistent dry cough, frequently worse at night or in the early hours
- •Waking at night because of breathing symptoms
- •Breathlessness or coughing during or after exercise
- •Symptoms triggered by cold air, dust, pollen, animals or smoke
- •Needing a reliever inhaler more than twice a week
- •Reduced peak expiratory flow readings compared with personal best
- •A reliever inhaler that works for a shorter time than usual, which is a warning sign
?Causes & Risk Factors
- •Airway inflammation driven by an allergic or eosinophilic response
- •Family history of asthma, eczema or hay fever
- •Allergen exposure including house dust mite, pollen, mould and animal dander
- •Respiratory infections, particularly viral infections in early childhood
- •Tobacco smoke, including second-hand exposure and exposure in pregnancy
- •Occupational exposures such as flour, isocyanates, wood dust and cleaning chemicals
- •Air pollution and fine particulate exposure
- •Exercise, especially in cold dry air, causing exercise-induced bronchoconstriction
- •Aspirin and other non-steroidal anti-inflammatory drugs in susceptible people
- •Obesity, gastro-oesophageal reflux and untreated allergic rhinitis as aggravating factors
Treatment Options
Asthma medicines fall into four groups that do different jobs. Mixing them up is the source of most avoidable harm in this condition. Short-acting relievers. Salbutamol and levosalbutamol relax airway smooth muscle within minutes and last a few hours. They treat the symptom, not the disease. Levosalbutamol is the purified active isomer of salbutamol and is dosed at a lower milligram figure, so the two are not interchangeable by number. Guidelines no longer support using either as the only asthma treatment. Inhaled corticosteroids. Budesonide, fluticasone and beclometasone suppress airway inflammation and are the foundation of asthma control. They do nothing acutely, which is why patients stop them when they feel well, and why they must not be stopped for that reason. Rinsing and spitting after each dose prevents most local side effects. Combination inhalers. An inhaled corticosteroid paired with a long-acting beta agonist in one device. The pairing matters: budesonide with formoterol can be used as both maintenance and reliever, because formoterol acts within minutes, whereas salmeterol with fluticasone cannot, because salmeterol is too slow in onset. Substituting one for the other in a maintenance and reliever regimen is a genuine safety error. Leukotriene receptor antagonists. Montelukast is a once-daily tablet for prophylaxis and chronic treatment. It carries an FDA boxed warning for serious neuropsychiatric events added in March 2020, and for allergic rhinitis the FDA instructs prescribers to reserve it for patients who cannot tolerate or do not respond to alternatives. It is not a reliever and never was. Anticholinergic bronchodilators. Ipratropium and tiotropium widen airways through a separate receptor system, giving additive bronchodilation, and are commonly combined with a beta agonist in acute care and in chronic obstructive pulmonary disease. Oral corticosteroids such as prednisolone and methylprednisolone are used in short courses for attacks. Repeated courses signal that maintenance treatment is inadequate rather than that the attacks were unavoidable.
Medications for Asthma
Asthalin Inhaler
Salbutamol · 100mcg
Cipla Limited
$10
USD
Levolin Inhaler
Levosalbutamol · 50mcg
Cipla Limited
$28
USD
Duolin Inhaler
Levosalbutamol/Ipratropium · 120 mcg
Cipla Limited
$20
USD
Budecort 200 Inhaler
Budesonide · 200mcg
Cipla Limited
$27
USD
Foracort 200 Inhaler
Budesonide/Formoterol · 200mcg
Cipla Limited
$21
USD
Foracort 400 Inhaler
Budesonide/Formoterol · 400mcg
Cipla Limited
$26
USD
Symbicort 160mcg/4.5mcg Turbuhaler
Budesonide/Formoterol · 160mcg + 4.5mcg
AstraZeneca Pharma India Ltd
$30
USD
Seroflo 125 Inhaler
Salmeterol/Fluticasone · 125mcg
Cipla Limited
$19
USD
Seroflo 250 Inhaler
Salmeterol/Fluticasone · 250mcg
Cipla Limited
$26
USD
Montair 10mg
Montelukast · 10mg
Cipla Limited
$27
USD
Montair 5mg Chewable Tablet
Montelukast · 5mg
Cipla Limited
$20
USD
Montair LC
Montelukast/Levocetirizine · 10 mg + 5 mg
Cipla Limited
$45
USD
Why Choose Generic?
Asthma is treated for years or decades, and the cost of a daily controller inhaler compounds. That makes it one of the clearest cases for generic and internationally sourced brands. Salbutamol, levosalbutamol, budesonide, formoterol, fluticasone, salmeterol, ipratropium and montelukast have all been off patent for years. The molecules in a $10 inhaler and a $60 inhaler are the same molecules at the same strengths. What differs between products is the device rather than the drug. A pressurised inhaler, a dry powder rotahaler, a breath-actuated device and a nebuliser respule deliver the same active ingredient with very different technique requirements, and matching the device to the patient matters more than the brand printed on it. Every product listed here is manufactured under WHO-GMP conditions by established Indian manufacturers including Cipla, which supplies inhaled respiratory medicines to regulated markets worldwide. Prescription requirements apply in the United States, United Kingdom, Canada and Australia.
Frequently Asked Questions
What is the difference between a reliever and a preventer inhaler?
A reliever, usually salbutamol or levosalbutamol, relaxes the airway muscle within minutes and lasts a few hours. It treats the symptom. A preventer, usually an inhaled corticosteroid, suppresses the airway inflammation that causes attacks in the first place, and produces no immediate sensation. Relievers work when you feel bad. Preventers work when you feel fine, which is why they get stopped and should not be.
Is it safe to use a reliever inhaler as my only asthma treatment?
Current guidance says no. The Global Initiative for Asthma no longer recommends short-acting reliever monotherapy at any step of treatment for adults and adolescents. Reliever-only treatment leaves the underlying inflammation untreated and is the pattern most strongly associated with severe attacks. Needing a reliever more than twice a week is a signal to have controller treatment reviewed.
How do I know if my asthma is controlled?
Well controlled asthma generally means daytime symptoms no more than twice a week, no waking at night from asthma, no limitation on normal activity including exercise, and reliever use no more than twice a week. Failing any of those is a reason for review. Getting through reliever canisters quickly is one of the more reliable warning signs.
Which inhalers can be used as both preventer and reliever?
Only combinations containing formoterol, such as budesonide with formoterol. Formoterol has a fast onset as well as a long duration, so extra doses relieve symptoms. Combinations containing salmeterol cannot be used this way because salmeterol is slow in onset and repeated extra doses would deliver an unsafe amount of a long-acting beta agonist.
Why do I need to rinse my mouth after using a steroid inhaler?
Oral thrush, hoarseness and throat irritation come from drug deposited in the mouth and throat rather than from drug reaching the lungs. Rinsing and spitting after each dose removes most of the cause. Using a spacer with a pressurised inhaler reduces mouth deposition further and improves the amount that reaches the airways.
Does montelukast replace an inhaler?
No. Montelukast is a controller tablet for prophylaxis and chronic treatment, not a reliever, and inhaled corticosteroids are more effective than leukotriene antagonists for persistent asthma in most patients. Montelukast also carries an FDA boxed warning for serious neuropsychiatric events. It has a defined role, including exercise-induced bronchoconstriction and asthma with prominent allergic rhinitis, but it is not a substitute for inhaled treatment.
Which inhaler device should I use?
A pressurised metered dose inhaler needs coordination between pressing and breathing in, and works considerably better with a spacer. A dry powder device needs no coordination but requires a fast deep breath, which young children and patients mid-attack often cannot produce. Breath-actuated inhalers fire on inhalation. Nebuliser respules need no technique but are slow and require equipment. Technique often matters more than dose.
When does an asthma attack need emergency care?
Emergency assessment is needed when the reliever inhaler is not working or wears off within a couple of hours, when speaking in full sentences is difficult, when breathing is so hard that eating or sleeping is not possible, when lips or fingertips look blue, or when symptoms are worsening despite treatment. Waiting to see whether it settles is the main cause of preventable harm in asthma.
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Medical Disclaimer: This page is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional before starting, changing, or stopping any medication. Individual responses to treatment vary. SafeRxPills is an online pharmacy, we do not diagnose conditions or provide medical consultations.