Non-corticosteroid therapy for the long-term control of asthma

The non-corticosteroids approved for the maintenance therapy of persistent asthma include the long-acting inhaled beta 2 agonists (LABAs), leukotriene modifiers, chromones, theophylline and omalizumab. This review assesses the benefits and risks of each in relation to the inhaled corticosteroids and each other. Neither the LABAs nor omalizumab should be used as monotherapy for persistent asthma. There is no evidence of clinically significant differences in efficacy between the chromones, theophylline and leukotriene modifiers as monotherapy in mild-moderate persistent asthma; thus the choice of one therapy over the other is a clinical decision based upon differences in safety, acceptability to the patient and ease of use. Although there is significant variability in response to various therapies, non response to one therapy is not predictive of response to another. Neither studies of phenotypes nor genotypes have provided acceptable determinants of response as yet. As adjunctive therapy to the inhaled corticosteroids for moderate-severe persistent asthma, the LABAs provide superior improvement in lung function and reduction in exacerbations relative to higher doses of inhaled corticosteroids and the other noncorticosteroids used as adjunctive therapy. Thus, LABAs remain the adjunctive therapy of choice in patients not adequately controlled on low-medium dose inhaled corticosteroids. Omalizumab has not been compared with the other adjunctive therapies, so its relative efficacy is unknown. However, it is the only adjunctive therapy added to the combination of an inhaled corticosteroid plus LABA to demonstrate further improvement in a controlled clinical trial.