1) Classification of anti-asthma drugs

A. Controllers (long-term)

1. Inhaled corticosteroids (ICS)
   • Beclomethasone, Budesonide, Fluticasone, Mometasone, Ciclesonide
2. LABA (always with ICS in asthma)
   • Salmeterol, Formoterol
3. LAMA
   • Tiotropium (add-on)
4. Leukotriene modifiers
   • Montelukast, Zafirlukast (CysLT1 antagonists), Zileuton (5-lipoxygenase inhibitor)
5. Mast cell stabilizers
   • Cromolyn, Nedocromil (less used now)
6. Methylxanthines
   • Theophylline (limited use due to toxicity/interactions)
7. Biologics (severe asthma phenotypes)
   • Anti-IgE: Omalizumab
   • Anti-IL-5/IL-5R: Mepolizumab, Reslizumab, Benralizumab
   • Anti-IL-4Rα: Dupilumab
   • Anti-TSLP: Tezepelumab

B. Relievers (quick symptom relief)

1. SABA: Salbutamol (albuterol), Terbutaline
2. Low-dose ICS-formoterol (preferred reliever in many current guidelines)
3. Anticholinergic (acute add-on): Ipratropium
4. Systemic corticosteroids for moderate-severe exacerbation

2) Core pharmacology for exams (MOA, uses, adverse effects)

3) Stepwise treatment (adult/adolescent exam framework)

1. Step 1-2 (mild asthma)
   • Preferred: as-needed low-dose ICS-formoterol
   • Alternative: daily low-dose ICS + SABA PRN
2. Step 3
   • Low-dose ICS/LABA maintenance (or MART with ICS-formoterol)
3. Step 4
   • Medium-dose ICS/LABA (or MART escalation)
4. Step 5
   • High-dose ICS/LABA ± LAMA, assess phenotype, add biologic if indicated
   • Consider low-dose oral steroids only if unavoidable

4) Acute severe asthma (status asthmaticus) drug protocol

1. Oxygen to target SpO2 ~93-95% (adults)
2. Repeated/nebulized SABA (salbutamol)
3. Add ipratropium in moderate-severe attacks
4. Early systemic corticosteroid
   • Prednisolone oral or hydrocortisone/methylpred IV
5. If poor response/severe:
   • IV magnesium sulfate (single dose)
   • Consider IV β2 agonist/aminophylline in selected ICU settings
6. Monitor: PEFR/FEV1, RR, HR, SpO2, ABG (if tiring/hypercapnia), electrolytes (K+)

5) Biologics selection (very high-yield viva topic)

• Omalizumab: allergic asthma, elevated IgE, sensitization evidence
• Mepolizumab/Reslizumab/Benralizumab: eosinophilic severe asthma
• Dupilumab: eosinophilic or steroid-dependent asthma, Type-2 inflammation
• Tezepelumab: broader severe asthma including non-eosinophilic phenotypes in some cases

6) Common exam “must-write” cautions

• Never use LABA alone in asthma
• Prefer inhaled route to reduce systemic toxicity
• Rinse mouth after ICS to prevent thrush
• Montelukast: counsel regarding neuropsychiatric effects
• Theophylline: narrow therapeutic index, drug interaction prone
• Reassess control periodically and step down after sustained control

7) Short note format (ready for theory paper)

1. Bronchodilators: SABA, LABA, anticholinergics, methylxanthines
2. Anti-inflammatory drugs: ICS, systemic corticosteroids, leukotriene modifiers, mast cell stabilizers
3. Biologics for severe asthma
4. Stepwise therapy and acute exacerbation protocol
5. Precautions/adverse effects and monitoring

1) Reliever drugs (acute symptoms)

• Salbutamol (albuterol), inhaled
  • MDI: 100 mcg/puff, give 1-2 puffs PRN (with spacer)
  • Nebulization in exacerbation: 2.5-5 mg every 20 min for 1 hour, then every 1-4 h as needed or continuous in severe attack
• Formoterol + low-dose ICS (as reliever in MART/AIR approach)
  • Common inhaler strengths: budesonide/formoterol 160/4.5 mcg
  • PRN: 1 inhalation as needed, may repeat; follow product/day maximum (often up to 8-12 inhalations/day total depending regimen)
• Ipratropium bromide (acute severe add-on)
  • Neb: 0.5 mg every 20 min for first hour (with SABA), then spaced

2) Controller drugs (maintenance)

A. Inhaled corticosteroids (usual adult daily dose ranges)

• Budesonide DPI/MDI: low 200-400 mcg/day, medium >400-800, high >800
• Beclomethasone HFA (extrafine): low 100-200 mcg/day, medium >200-400, high >400
• Fluticasone propionate: low 100-250 mcg/day, medium >250-500, high >500
• Mometasone: low 200 mcg/day, medium 400, high >400

B. ICS/LABA fixed combinations (common adult doses)

• Budesonide/Formoterol
  • Maintenance: 1-2 inhalations of 160/4.5 mcg BID
  • MART: maintenance + same inhaler PRN
• Fluticasone/Salmeterol
  • 100/50, 250/50, 500/50 mcg, usually 1 inhalation BID
• Beclomethasone/Formoterol
  • Commonly 100/6 mcg, typically 1-2 puffs BID

C. LAMA

• Tiotropium Respimat: 2.5 mcg (2 puffs of 1.25 mcg) once daily (total 5 mcg/day in many adult regimens)

D. Leukotriene modifiers

• Montelukast: 10 mg once daily (night)
• Zafirlukast: 20 mg BID (empty stomach)
• Zileuton (ER): 1200 mg BID (monitor LFT)

E. Methylxanthine

• Theophylline SR: usually 200-400 mg/day start low; titrate to serum therapeutic range (narrow TI)

3) Systemic corticosteroids in exacerbation

• Prednisolone/Prednisone (oral): 40-50 mg once daily for 5-7 days (adult)
• Hydrocortisone IV: 100 mg every 6-8 h (if unable to take oral/severe)
• Methylprednisolone IV: 40-80 mg/day divided doses (hospital protocols vary)

4) Magnesium sulfate (severe, poor response)

• IV Magnesium sulfate: 2 g IV infusion over 20-30 min (adult standard emergency dose)

5) Biologics (severe asthma, phenotype-based)

• Omalizumab: SC every 2-4 weeks, dose by IgE level + body weight
• Mepolizumab: 100 mg SC every 4 weeks
• Benralizumab: 30 mg SC every 4 weeks for 3 doses, then every 8 weeks
• Dupilumab: 200 or 300 mg SC every 2 weeks (loading dose based on regimen)
• Tezepelumab: 210 mg SC every 4 weeks
• Reslizumab: 3 mg/kg IV every 4 weeks

6) Pediatric quick doses (very asked in exams)

• Salbutamol neb: 0.15 mg/kg (min 2.5 mg, max 5 mg) every 20 min initially
• Ipratropium neb:
  • <20 kg: 0.25 mg
  • ≥20 kg: 0.5 mg every 20 min for first hour
• Prednisolone oral: 1-2 mg/kg/day (max usually 40-50 mg) for 3-5 days
• Dexamethasone: 0.6 mg/kg (max 12-16 mg), 1-2 doses (protocol dependent)
• Montelukast:
  • 6 months-5 y: 4 mg
  • 6-14 y: 5 mg
  • ≥15 y: 10 mg once daily

7) Viva one-liners

• LABA never as monotherapy in asthma
• ICS is cornerstone controller
• MART with ICS-formoterol reduces exacerbations
• Check technique/adherence before stepping up
• Rinse mouth after ICS