When Inhaled Corticosteroids Aren't Enough for Allergic Asthma

Medically Reviewed By Marc Meth, MD, FACAAI, FAAAI
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Find out what to do when your inhaler doesn’t relieve symptoms like wheezing and shortness of breath.

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Allergic asthma is the most common form of asthma. Just like other asthma types, it can cause shortness of breath, coughing, and wheezing. However, in allergic asthma, these symptoms are often triggered by an allergic reaction to dust mites, animal dander, mold, pollen, or other substances in the environment. 

Inhaled corticosteroids are the most effective long-term treatment for persistent allergic asthma. These medications reduce inflammation in the lungs and prevent asthma flare-ups in most people who take them — but they don’t help everyone. Up to 10% of people with severe asthma won’t get relief from corticosteroids alone.

If your symptoms don’t improve with high-dose inhaled corticosteroids, your doctor may refer to your asthma as “treatment-resistant asthma” or “difficult-to-treat asthma.” Certain factors can make asthma harder to treat, including:

  • having another health condition such as obesity, depression, or chronic obstructive pulmonary disease (COPD)
  • not following your doctor’s directions for taking inhaled corticosteroids 
  • not using your inhaler correctly
  • being exposed to tobacco smoke, pollution, or allergy triggers like mold, animal dander and pollen

When steroids aren’t enough to control allergic asthma symptoms, what should you do next?

Signs that your inhaled corticosteroids aren’t working 

The most obvious sign that your allergic asthma isn’t well controlled is when exposure to your allergy triggers causes symptoms like:

  • wheezing
  • coughing
  • shortness of breath
  • a tight feeling in your chest

These are some other signs that an inhaled corticosteroid isn’t managing your allergic asthma symptoms well enough:

  • You have daytime symptoms like wheezing and shortness of breath more than twice a week.
  • You need to use your quick-relief inhaler to control symptoms more than twice a week.
  • You wake up at night with asthma symptoms more than twice a month.
  • Asthma symptoms force you to limit your activities.

What to do next

The next step if inhaled corticosteroids aren’t controlling your asthma symptoms is to see your doctor and discuss other treatment options. 

Tell your doctor about any side effects or other problems you’ve had while taking inhaled corticosteroids. Discuss your inhalation technique to make sure you’re using the medicine correctly. And go over your list of asthma triggers to make sure you’re doing everything possible to avoid them.

Then you and your doctor can develop a new asthma treatment plan, which could include adding another long-term controller or another type of medication.

Your treatment options

To manage difficult-to-treat allergic asthma, your doctor might consider adding one of the following medications to your treatment plan. 

Other long-term asthma controllers

These medicines are taken daily to bring down inflammation in the lungs and prevent asthma symptoms, and include:

  • leukotriene modifiers such as montelukast (Singulair), zafirlukast (Accolate), or zileuton (Zyflo)
  • combination medications that blend a long-acting beta 2 agonist (LABA) with an inhaled corticosteroid, such as formoterol and budesonide (Symbicort), formoterol and mometasone (Dulera), and salmeterol and fluticasone (Advair)
  • bronchodilators such as tiotropium (Spiriva)

Oral corticosteroids

Corticosteroid pills are a treatment for allergic asthma that isn’t improving on inhaled corticosteroids or other asthma medicines. Your doctor might prescribe an oral corticosteroid together with a high-dose inhaled corticosteroid, a long-acting bronchodilator, or a quick-relief medicine.

Oral corticosteroids are usually prescribed for only short periods of time, because they can cause side effects like:

Sometimes doctors prescribe oral corticosteroids long-term to manage severe asthma. Make sure you understand the risks and benefits of these drugs before you take them.

Macrolide antibiotics

Macrolide antibiotics like azithromycin and erythromycin kill bacteria to prevent infection and reduce the number of inflammation-producing white blood cells in the airways. People with poorly controlled asthma who take macrolide antibiotics may have fewer flares, but staying on these medicines long-term has risks like antibiotic resistance.

Biologics

These newer-generation asthma medicines target the specific immune cells that cause asthmatic inflammation. A biologic drug may reduce the number of asthma flares you get.

Five biologics are approved by the Food and Drug Administration (FDA) to treat severe asthma:

  • benralizumab (Fasenra)
  • dupilumab (Dupixent)
  • mepolizumab (Nucala)
  • omalizumab (Xolair)
  • reslizumab (Cinqair)
  • tezepelumab-ekko (Tezspire)

Your allergist will perform tests to find out which of these medicines works best against your type of asthma. Biologics come as an injection or an infusion that you receive at your doctor’s office or self-inject once every 2 to 8 weeks.

Immunotherapy

This treatment gradually exposes your immune system to increasing amounts of your allergic trigger until you build up a tolerance to it. Over time, you become less sensitive to the substance, and less likely to have an allergic reaction when you’re exposed. 

Immunotherapy comes in two types:

  • allergy shots 
  • a pill you take every day that dissolves under your tongue

If immunotherapy is part of your treatment plan, you’ll work with your allergist and/or pulmonologist to receive the therapy safely over time.

Lifestyle changes

A few changes to your daily routine can also reduce inflammation and help prevent asthma attacks. Consider trying the following:

  • Keep a symptom-tracking diary to figure out which allergens cause your asthma attacks, and then try to avoid those triggers. 
  • Eat more fruits, vegetables, and whole grains and less saturated fat.
  • Exercise regularly to improve your lung function and quality of life.
  • Lose 5 to 10% of your body weight if you’re very overweight.
  • Quit smoking. Cigarette smoke is a big trigger of asthma attacks.

Talk to your doctor about other changes you can make in your daily routine to control allergic asthma.

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Medical Reviewer: Marc Meth, MD, FACAAI, FAAAI
Last Review Date: 2022 Oct 31
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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
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