Asthmatics are very familiar with breathing treatments to manage symptoms. Many asthma sufferers keep a nebulizer machine at home to take prescribed liquid inhalation medicines. The device has an air pump that aerosolizes liquid asthma medications into a fine mist that is inhaled through a face mask. One of the greatest product innovations for asthmatics was the invention of pocket-sized portable inhalers. They make it possible to precisely meter dosages of both liquid and dry inhalant medications.

Albuterol sulfate is probably the most prescribed rescue inhaler for asthma sufferers who have acute asthma attacks. It is often available at special generic pricing at participating pharmacies. Some doctor's offices also keep it on hand as samples to give away to first-time users and low income patients. Ipratropium bromide (Atrovent) is another fast acting inhaler medication used to mitigate symptoms of an asthma attack in progress. A newer drug that is an analog to albuterol is the brand name drug Xopenex which is manufactured by Sunovion Pharmaceuticals. Though both albuterol and Xopenex have similar reported side effects, Xopenex may be better tolerated by those who cannot tolerate albuterol. An increased heart rate and palpitations are listed as side effects for both medications. There are reports that Xopenex may work better for those who are troubled by heart-related side effects.

Other inhaled medications to treat asthma are classified as long-term maintenance drugs that are not to be used to treat an acute asthma attack. They are mostly corticosteroid medications that are inhaled directly into the lungs via an inhalation device. They are not meant to treat the immediate and potentially life-threatening symptoms of an asthma attack in progress. These drugs include the generics fluticasone, ciclesonide, mometasone, budesonide and beclomethasone that are also marketed under various brand names.

Corticosteroids are a type of anti-inflammatory medicine. Corticosteroid overdose occurs when someone accidentally or intentionally takes more than the normal or recommended amount of this medication.

Corticosteroids come in many forms, including:

• Creams and ointments that are applied to the skin
• Inhaled forms that are breathed into the nose or lungs
• Pills or liquids that are swallowed
• Injected formulas delivered to the skin, joints, muscles, or veins

Most corticosteroid overdoses occur with pills and liquids.

This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.

• Alclometasone dipropionate
• Amcinonide
• Augmented betamethasone dipropionate
• Beclomethasone dipropionate
• Betamethasone
• Betamethasone benzoate
• Betamethasone dipropionate
• Betamethasone sodium phosphate
• Betamethasone valerate
• Clobetasol propionate
• Clocortolone pivalate
• Cortisone
• Desonide
• Desoximetasone
• Dexamethasone
• Dexamethasone acetate
• Dexamethasone sodium phosphate
• Diflorasone acetonide
• Diflorasone diacetate
• Flunisolide
• Fluocinolone acetonide
• Fluocinonide
• Fluocinolone acetonide
• Flurandrenolide
• Fluticasone propionate
• Halcinonide
• Halobetasol propionate
• Hydrocortisone
• Hydrocortisone acetate
• Hydrocortisone butyrate
• Hydrocortisone sodium phosphate
• Hydrocortisone valerate
• Methylprednisolone
• Methylprednisolone acetate
• Methylprednisolone sodium succinate
• Mometasone furoate
• Prednisolone acetate
• Prednisolone sodium phosphate
• Prednisolone tebutate
• Prednisone
• Triamcinolone
• Triamcinolone acetonide
• Triamcinolone diacetate
• Triamcinolone hexacetonide

Note: This list may not be all inclusive.

• Alclometasone dipropionate (Delonal)
• Augmented betamethasone dipropionate (Deprolene)
• Beclomethasone dipropionate (Diprosone)
• Betamethasone sodium phosphate (Celestone)
• Betamethasone valerate (Valisone)
• Clobetasol propionate (Temovate)
• Clocortolone pivalate (Cloderm)
• Desonide (DesOwen, Tridesilon)
• Desoximetasone (Topicort)
• Dexamethasone (Decadron)
• Fluocinonide (Lidex)
• Flunisolide (AeroBid)
• Fluocinolone acetonide (Synalar)
• Flurandrenolide (Cordran)
• Fluticasone propionate (Cutivate)
• Halcinonide (Halog)
• Hydrocortisone (Cortef)
• Hydrocortisone sodium phosphate (Solu-Cortef)
• Hydrocortisone valerate (Westcort)
• Methylprednisolone (Medrol)
• Methylprednisolone sodium succinate (Solu-Medrol)
• Mometasone furoate (Elocon)
• Prednisolone sodium phosphate (Pred Fonte)
• Prednisone (Deltasone)
• Triamcinolone acetonide (Aristocort)

Note: This list may not be all inclusive.

Symptoms of corticosteroid overdose can include:

• Burning or itching skin
• Convulsions
• Deafness
• Depression
• Dry skin
• High blood pressure
• Muscle weakness
• Nervousness
• Psychosis
• Sleepiness
• Stopping of menstrual cycle
• Swelling in lower legs, ankles, or feet
• Weakness
• Worsening of health conditions such as ulcers, diabetes

Determine the following information:

• Patient's age, weight, and condition (for example, is the person awake or alert?)
• Name of the product (ingredients and strengths, if known)
• Time it was swallowed
• Amount swallowed

However, DO NOT delay calling for help if this information is not immediately available.

The National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.

This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.

See: Poison control center - emergency number

The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. The patient may receive:

• Activated charcoal
• EKG
• Fluids through a vein (by IV)
• Laxative
• Medications to treat fluid and electrolyte changes
• Tube through the mouth into the stomach to wash out the stomach (gastric lavage)

Most cases of corticosteroid overdose result in relatively minor fluid and electrolyte changes. If the problem is severe enough to cause heart rhythm disturbances, the outlook may be more grave.

Nikkanen HE, Shannon MW. Endocrine toxicology. In: Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 16.

Perhaps the most important step in controlling asthma is establishing a partnership between doctor and patient (whether child or adult) to create a specific, customized plan for proactively monitoring and managing symptoms. It is essential to be certain that someone who has asthma understands (and takes an active part in deciding) what needs to be accomplished, including reducing exposure to allergens, taking medical tests to assess the severity of symptoms, and possibly using medications. The treatment plan should be written down, consulted at every visit, and adjusted according to changes in symptoms.

The most effective treatment for asthma is identifying triggers, such as pets or aspirin, and limiting or eliminating exposure to them. If trigger avoidance is insufficient, medical treatment is available. Desensitization has been suggested as a possible cure. Additionally, some trial subjects were able to remove their symptoms by retraining their breathing habits with the Buteyko method.

Other forms of treatment include relief medication, prevention medication, long-acting β2-agonists, and emergency treatment.

The specific medical treatment recommended to patients with asthma depends on the severity of their illness and the frequency of their symptoms. Specific treatments for asthma are broadly classified as relievers, preventers and emergency treatment. The Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (EPR-2) of the U.S. National Asthma Education and Prevention Program, and the British Guideline on the Management of Asthma are broadly used and supported by many doctors.

The Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma of the U.S. National Asthma Education and Prevention Program, released in 2007, presented a focused 6-step approach to asthma management, based on four principles that act as a blueprint to guide individualized treatment: * Frequent and regular assessment of symptoms * Patient education * Control of environmental triggers * Systematic evaluation of the effectiveness and safety of medications. The 2007 revised NAEPP guidelines differ from the earlier version in an increased focus on asthma control and individualized treatment, reorganizing the goals of treatment to differentiate risk from impairment. They specify defined measures that should prompt a decision to "step up" or "step down" the intensity of treatment, and they emphasize education and integrated decision-making to encourage patient self-management. Bronchodilators are recommended for short-term relief in all patients. For those who experience occasional attacks, no other medication is needed. For those with mild persistent disease (more than two attacks a week), low-dose inhaled glucocorticoids or alternatively, an oral leukotriene modifier, a mast-cell stabilizer, or theophylline may be administered. For those who suffer daily attacks, a higher dose of glucocorticoid in conjunction with a long-acting inhaled β-2 agonist may be prescribed; alternatively, a leukotriene modifier or theophylline may substitute for the β-2 agonist. In severe asthma, oral glucocorticoids may be added to these treatments during severe attacks.

Symptomatic control of episodes of wheezing and shortness of breath is generally achieved with fast-acting brochodilators. These are typically provided in pocket-sized, metered-dose inhalers (MDIs). In young sufferers, who may have difficulty with the coordination necessary to use inhalers, or those with a poor ability to hold their breath for 10 seconds after inhaler use (generally the elderly), an asthma spacer is used. The spacer is a plastic cylinder that mixes the medication with air in a simple tube, making it easier for patients to receive a full dose of the drug and allows for the active agent to be dispersed into smaller, more fully inhaled bits.

A nebulizer which provides a larger, continuous dose can also be used. Nebulizers work by vaporizing a dose of medication in a saline solution into a steady stream of foggy vapour, which the patient inhales continuously until the full dosage is administered. There is no clear evidence, however, that they are more effective than inhalers used with a spacer. Nebulizers may be helpful to some patients experiencing a severe attack. Such patients may not be able to inhale deeply, so regular inhalers may not deliver medication deeply into the lungs, even on repeated attempts. Since a nebulizer delivers the medication continuously, it is thought that the first few inhalations may relax the airways enough to allow the following inhalations to draw in more medication.

Relievers include: * Short-acting, selective beta2-adrenoceptor agonists, such as salbutamol (albuterol USAN), levalbuterol, terbutaline and bitolterol. Tremors, the major side effect, have been greatly reduced by inhaled delivery, which allows the drug to target the lungs specifically; oral and injected medications are delivered throughout the body. There may also be cardiac side effects at higher doses (due to Beta-1 agonist activity), such as elevated heart rate or blood pressure. Patients must be cautioned against using these medicines too frequently, as with such use their efficacy may decline, producing desensitization resulting in an exacerbation of symptoms which may lead to refractory asthma and death. * Older, less selective adrenergic agonists, such as inhaled epinephrine and ephedrine tablets, have also been used. Cardiac side effects occur with these agents at either similar or lesser rates to albuterol. When used solely as a relief medication, inhaled epinephrine has been shown to be an effective agent to terminate an acute asthmatic exacerbation. In emergencies, these drugs were sometimes administered by injection. Their use via injection has declined due to related adverse effects. * Anticholinergic medications, such as ipratropium bromide may be used instead. They have no cardiac side effects and thus can be used in patients with heart disease; however, they take up to an hour to achieve their full effect and are not as powerful as the β2-adrenoreceptor agonists. * Inhaled glucocorticoids are usually considered preventive medications while oral glucocorticoids are often used to supplement treatment of a severe attack. They should be used twice daily in children with mild to moderate persistent asthma. A randomized controlled trial has demonstrated the benefit of 250 microg beclomethasone when taken as an as-needed combination inhaler with 100 microg of albuterol. Long-acting bronchodilators (LABD) are similar in structure to short-acting selective beta2-adrenoceptor agonists, but have much longer side chains resulting in a 12-hour effect, and are used to give a smoothed symptomatic relief (used morning and night). While patients report improved symptom control, these drugs do not replace the need for routine preventers, and their slow onset means the short-acting dilators may still be required. In November 2005, the American FDA released a health advisory alerting the public to findings that show the use of long-acting β2-agonists could lead to a worsening of symptoms, and in some cases death. In December 2008, members of the FDA's drug-safety office recommended withdrawing approval for these medications in children. Discussion is ongoing about their use in adults.

Currently available long-acting beta2-adrenoceptor agonists include salmeterol, formoterol, bambuterol, and sustained-release oral albuterol. Combinations of inhaled steroids and long-acting bronchodilators are becoming more widespread; the most common combination currently in use is fluticasone/salmeterol (Advair in the United States, and Seretide in the United Kingdom). Another combination is budesonide/formoterol which is commercially known as Symbicort.

A recent meta-analysis of the roles of long-acting beta-agonists may indicate a danger to asthma patients. The study, published in the Annals of Internal Medicine in 2006, found that long-acting beta-agonists increased the risk for asthma hospitalizations and asthma deaths 2- to 4-fold, compared with placebo. "These agents can improve symptoms through bronchodilation at the same time as increasing underlying inflammation and bronchial hyper-responsiveness, thus worsening asthma control without any warning of increased symptoms," said Shelley Salpeter in a press release after the publication of the study. The release goes on to say that "Three common asthma inhalers containing the drugs salmeterol or formoterol may be causing four out of five US asthma-related deaths per year and should be taken off the market". This assertion is viewed by many asthma specialists as being inaccurate. Dr. Hal Nelson, in a recent letter to the Annals of Internal Medicine, points out the following:

: "Salpeter and colleagues also assert that salmeterol may be responsible for 4000 of the 5000 asthma-related deaths that occur in the United States annually. However, when salmeterol was introduced in 1994, more than 5000 asthma-related deaths occurred per year. Since the peak of asthma deaths in 1996, salmeterol sales have increased about 5-fold, while overall asthma mortality rates have decreased by about 25%, despite a continued increase in asthma diagnoses. In fact, according to the most recent data from the National Center for Health Statistics, U.S. asthma mortality rates peaked in 1996 (with 5667 deaths) and have decreased steadily since. The last available data, from 2004, indicate that 3780 deaths occurred. Thus, the suggestion that a vast majority of asthma deaths could be attributable to LABA use is inconsistent with the facts." Dr. Shelley Salpeter, in a letter to the Annals of Internal Medicine, responds to the comments of Dr. Nelson, as follows: : "It is true that the asthma death rate increased after salmeterol was introduced, then peaked and is now starting to decline despite continued use of the long-acting beta-agonists. This trend in death rates can best be explained by examining the ratio of beta-agonist use to inhaled corticosteroids... In the recent past, inhaled corticosteroid use has increased steadily while long-acting beta-agonist use has begun to stabilize and short-acting beta-agonist use has declined... Using this estimate, we can imagine that if long-acting beta-agonists were withdrawn from the market while maintaining high inhaled corticosteroid use, the death rate in the United States could be reduced significantly..." ;