Pharmacotherapy of asthma is unique in several ways. First, asthma is characterized by airway inflammation, bronchial hyperresponsiveness and reversible bronchospasm. Standard asthma therapy therefore consists of an anti-inflammatory medication to suppress airway inflammation and a fast-acting bronchodilator to relieve bronchospasm as needed.The use of two different classes of medication to treat different aspects of the same disease is not an easy concept for patients to grasp. Since relief with bronchodilators is immediate and perceptible, there is often an over-usage of bronchodilators by patients, with a corresponding neglect of anti-inflammatory medications.Over-reliance on bronchodilators leading to uncontrolled airway inflammation is a cause of majority of asthma morbidity and mortality.

Second, most of the first-line agents are administered via inhalation. The choice of which medication to use is often framed within the context of the delivery device, dose frequency, lung deposition, systemic bioavailability, educational requirement for proper medication and inhaler usage, patient adherence and motor coordination. These unique features of asthma therapy add several layers of complexity to the pharmacotherapy of asthma. These issues have to be factored in for each and every patient and are critical in determining the ultimate success of asthma therapy.

Third, unlike adjusting medication and diet to achieve a low glycosylated hemoglobin level, there is no equivalent biomarker for asthma. In the past, therapeutic endpoints have included spirometry, peak flow rates, clinical symptoms, and bronchial hyperresponsiveness.The ability to quantitate airway inflammation with exhaled nitric oxide and sputum eosinophil may change how management of inhaled corticosteroids is handled in the future. The use of validated simple asthma control questionnaires to adjust medications and improve asthma control may also redefine treatment outcomes in asthma.

Inhaled Corticosteroids in Asthma
Inhaled corticosteroids (ICS) remain the most efficacious therapy for chronic persistent asthma for all age groups and for different levels of disease severity.As the main anti-inflammatory therapy in asthma, it is effective in controlling the clinical manifestations of asthma and in reducing airway inflammation. The efficacy of inhaled corticosteroids is now confirmed in new onset asthma, and in mild persistent asthma for improving asthma control, preventing exacerbations and reducing hospitalizations. It is superior to mast cell stabilizers and leukotriene antagonists as monotherapy. Regular use of inhaled corticosteroids was superior to intermittent-use inhaled corticosteroids or daily leukotriene antagonist therapy in improving lung function, reducing asthma symptoms, and reducing bronchial hyperresponsiveness. The regular use of inhaled corticosteroid was a major reason for significant reductions in asthma morbidity and mortality.

In choosing which inhaled corticosteroid to use, the delivery device, i.e. dry powder inhaler or metered dosed inhaler, and the best achievable technique by the patient are probably the most pragmatic criteria for the individual patient. Serial measurement of sputum eosinophil and exhaled nitric oxide has been shown to be useful in titrating inhaled corticosteroids in asthma in adults and children.