Optimizing Patient Care in Asthma During Pregnancy

Kristi Isaac Rapp, PharmD, AE-C, Clinical Assistant Professor; Lovie Lewis Rodgers, PharmD, Clinical Assistant Professor; Kyla Leon, PharmD; Adrienne Roberts, Pharmacy Student

Disclosures

US Pharmacist 

In This Article

Management: Pharmacologic Therapy

Asthma treatment can be divided into two categories: controller medications and rescue medications. Controller medications are used to prevent asthma symptoms, while rescue medications are used to relieve asthma symptoms.

Controller Medications

Inhaled Corticosteroids: Inhaled corticosteroids (ICSs), which help prevent and control inflammation, are the preferred controller therapy for asthmatic patients, including those who are pregnant. These medications have been shown to improve asthma symptoms and increase pulmonary function.[3] Currently available ICSs include beclomethasone, budesonide, ciclesonide, flunisolide, and fluticasone. Budesonide is preferred during pregnancy because of its proven efficacy and safety in numerous studies. A study of teratogenic effects of budesonide use during early pregnancy on 2,014 infants concluded that clinically significant teratogenic risk is unlikely when budesonide is used in early pregnancy.[13] Other ICSs have not been proven unsafe. Side effects of ICSs include cough, dysphonia, and oral candidiasis. To reduce the risk of thrush and dysphonia, patients should be counseled to rinse the mouth with warm water and then spit.[1] The ICS dosage depends upon the patient classification of severity and level of control. Preferred and alternative therapies for asthma control during pregnancy are discussed in Table 2.

Long-acting Beta Agonists (LABAs): LABAs, which are indicated in patients who are not controlled on ICSs alone, are the preferred add-on therapy. There is little evidence regarding the safety of LABAs in pregnancy; however, they are considered safe based on evidence available for short-acting beta agonists (SABAs). LABAs have a black box warning regarding increased risk of death. This risk was primarily associated with LABAs used as monotherapy, not in combination with an ICS. Side effects include tachycardia, tremor, and palpitations. Currently, formoterol and salmeterol are the two agents available; both are given twice daily.[1]

Theophylline: While theophylline is not a preferred adjunctive therapy in asthma, it may be used as an alternative in patients who are not adequately controlled on ICSs alone. One study followed a cohort of 824 pregnant patients with and 678 pregnant patients without asthma. There was no significant relationship between theophylline use and major congenital malformation or preterm birth.[14] If theophylline is used in pregnancy, a low dose is recommended, with maintenance serum concentrations of 5 mcg/mL to 12 mcg/mL.[3] Side effects of theophylline include nausea, palpitations, and insomnia.[10]

Cromolyn: Although cromolyn has an excellent safety profile, this agent is not preferred in pregnant patients with asthma. Studies have shown that cromolyn is less effective than ICSs; therefore, it is an alternative therapy for asthma during pregnancy.[3]

Leukotriene Modifiers: Montelukast and zafirlukast, two available leukotriene receptor antagonists (LTRAs), are not preferred therapies in asthma, but they may be used as an adjunctive alternative in persistent asthma.[1] In a study comparing 96 pregnant patients taking LTRAs with nonpregnant patients taking SABAs and patients without asthma, LTRA use was not associated with an increased risk of pregnancy loss, gestational diabetes, preeclampsia, low maternal weight gain, preterm delivery, or neonatal head circumference.[15]

There is limited evidence on the safety of zileuton, a 5-lipoxygenase inhibitor, in pregnancy. For this reason, its use is not recommended in pregnant patients.[3]

Immunomodulator: There are no adequate, well-controlled studies regarding the use of omalizumab in pregnancy. Omalizumab is indicated for patients over age 12 years who have moderate-to-severe allergic asthma and are inadequately controlled with ICSs. Omalizumab is administered by subcutaneous injection every 2 or 4 weeks. Currently, the manufacturer recommends that the drug be used in pregnancy only if it is clearly needed.[16]

Rescue Medications

SABAs: SABAs, such as albuterol, are the drugs of choice for asthma during pregnancy. Studies evaluating exposure to SABAs during pregnancy resulted in no significant relationship between SABA use and congenital malformations, preterm delivery rate, or intrauterine growth restriction.[1,11,14] SABAs have a rapid onset of action of 3 to 5 minutes and a duration of action of 4 to 6 hours. Side effects of these medications include tachycardia, tremor, and palpitations. Use of rescue medications more than twice weekly may indicate the need for additional controller therapy.[1]

Systemic Corticosteroids: Severe asthma and asthma exacerbations are associated with maternal and fetal mortality; therefore, the guidelines recommend the use of oral corticosteroids in pregnancy when indicated.[3] The use of systemic corticosteroids during pregnancy is associated with preeclampsia and with preterm and low-birthweight infants. Use of oral corticosteroids in the first trimester may be associated with cleft lip with or without cleft palate.[10] The recommended dosage of prednisone (or its equivalent) in poorly controlled patients is 40 mg to 60 mg daily in single or divided doses for 3 to 10 days.[3]

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