Table 3

Maintenance therapies

Maintenance therapiesComments
ICSCurrently used as a first-line maintenance agent in a number of national guidelines20 31 49 50; when using ICS, the lowest possible dose to effectively control symptoms should be used to prevent possible adverse effects of reduced growth and risk of adrenal suppression.
LABAUsed as an add-on therapy when dual ICS and SABA therapy is ineffective. In comparison to SABA, bronchodilation duration is prolonged to 12 hours.
Leucotriene receptor antagonists (eg, montelukast)Used as an add-on therapy in those who have poor symptom control despite ICS and LABA treatments20 24 27 30 32 49
There have been a number of concerns raised regarding possible adverse reactions to montelukast. These include neuropsychiatric features ranging from poor sleep to suicidal ideation.66
Long-acting muscarinic antagonists (eg, tiotropium)Used as an add-on therapy in those who have poor symptoms control despite ICS and LABA therapies
Oral theophyllineUsed as an add-on therapy, usually in those with uncontrolled symptoms despite several maintenance and reliever therapies
Monitoring of plasma level required on initiation of treatment and dose changes
BiologicsUse as an add-on therapy, under specialist care, in those who have poorly controlled symptoms despite being on several maintenance and reliever therapies. A number of biologic agents are available (table 6). Various individual biologics have been shown to reduce attacks, improve lung function and reduce oral corticosteroid use.18
  • ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonists; SABA, short-acting beta-2 agonist.