Treatment of the recalcitrant asthmatic

Treatment of "difficult" asthma requires good doctor-patient communication, patient education, and attention to precipitating factors as well as an aggressive drug regimen. Specific medications include inhaled sympathomimetic and anti-cholinergic bronchodilators, inhaled, oral and/or intravenous corticosteroids and, in certain circumstances, mast cell stabilizing drugs such as cromolyn sodium. The use of systemic theophyllines is currently undergoing critical reevaluation. There have been a number of recent developments in the search for steroid-sparing agents and drugs that inhibit inflammatory mediators felt to be important in the pathophysiology of asthma. Most of these drugs are still undergoing evaluation in multicentre clinical trials. The newer antiinflammatory agents, methotrexate and gold, should probably not be used on a routine basis except as part of randomized, ethically approved clinical trials.