Acute asthma exacerbation in adults - Emerging treatments

Pharmacogenomic therapy

Future treatment of asthma could be directed by patient genotype, with potential therapies including targeting beta-2 adrenoreceptor and leukotriene C4 synthase polymorphisms.[80]

Coadministration of an inhaled corticosteroid with a short-acting beta-2 agonist in mild exacerbations

There is emerging evidence that coadministration of an inhaled corticosteroid (ICS) with a short-acting beta-2 agonist can have beneficial effects in the management of a mild exacerbation. These effects can be seen in the absence of the administration of a systemic corticosteroid. Patients more likely to benefit are those who have not been previously using ICS. The role of ICS used with systemic corticosteroids is not well defined.[81] In patients previously using ICS, dose titration may reduce exacerbation.

Coadministration of an inhaled corticosteroid with a long-acting beta agonist

Initiation of a long-acting beta agonist concomitantly with an ICS is safe and significantly reduces asthma hospitalizations.[82][83] This combination is widely used as an anti-inflammatory reliever in routine asthma management as it reduces the risk of severe exacerbations and exposure to oral corticosteroids, when compared with a short-acting beta agonist (SABA) reliever. Studies have also shown that ICS-formoterol has comparable efficacy and safety to high-dose SABA.[84][85]

Leukotriene receptor antagonists

The addition of an oral leukotriene receptor antagonist to standard care for acute asthma exacerbations does not have a meaningful impact on clinical outcomes, and the currently available data do not support their routine use for this indication.[86] [ ] Intravenous formulations are not yet available outside research trials, but promising results have been reported. For example, intravenous montelukast in addition to standard therapy was shown to provide rapid bronchodilation (within 10 minutes).[87] Montelukast carries warnings for the potential risk of neuropsychiatric adverse events, including new-onset nightmares, behavioral and mood problems (e.g., agitation, hyperactivity, irritability, nervousness, aggression), and suicidal ideation.[1]

Proton-pump inhibitors

Although proton-pump inhibitor therapy results in a small, yet statistically significant, improvement in morning peak expiratory flow rates, this improvement is unlikely to be of clinical significance, and there is insufficient evidence to recommend empiric use of such therapy in the management of asthma.[88]