Although asthma death rates have declined, it continues to be a leading cause of missed work and school in the United States. The National Institute of Health (NIH) revised their asthma diagnosis and management guidelines in 2007. This over 600 page document has become the Holy Grail of asthma treatment and clinical research in the United States.

Whether a child or adult with asthma should have a daily controller medication is dependent on a whether the asthma is "persistent".

When is asthma persistent? Great Question!

Asthma is persistent when:

-There are limitations in normal routine (work/school) because of asthma. For example, huffing and puffing as you walk up one flight of stairs, noticing classmates or coworkers gliding by with ease.

-Symptoms of asthma (cough, wheezing, shortness of breath, or chest tightness) occur more than two days per week.

-Reliever inhaler is required more than two days per week (don't count the inhalations taken to prevent exercise-induced asthma).

-Night time awakenings from asthma symptoms occurs more than two nights per month.

-Lung function is less than 80 percent predicted by lung function test (Spirometry or Peak Flow Rate).

-There has been more than one severe asthma attack in the last 12 months.

The clincher here is that it only takes one of the above criteria to say your asthma is persistent, even if all the other criteria are fine.

When asthma control is not achieved with low-to-medium doses of inhaled steroids (for example: Flovent, Pulmicort, Asmanex, Qvar or Alvesco) the doctor must decide whether to:

-Prescribe a high dose of inhaled steroid

-Or use a combination of low-to-medium inhaled steroid and a Long Acting Beta Adrenergic Receptor Agonist (LABA)

-Or consider a combination of low-to-medium inhaled steroid and another asthma drug (for example Singulair or Theophyline).

The NIH guidelines emphasize the importance of inhaled steroids at every level of treatment for persistent asthma. But adding a LABA, or instead using another alternative combination is up to your doctor. The LABAs plus inhaled steroid have been readily available through combination inhalers (Advair Diskus, Advair HFA and Symbicort).

Any LABA containing inhalers have Boxed Warnings, which relate to the risk of asthma worsening and asthma death based on, primarily, a large clinical study that analyzed the adverse effects of LABAs (done years ago).

Nonetheless, asthma has become more manageable since the introduction of combination inhalers containing LABA plus inhaled steroid.

Last June, a third LABA containing inhalant became available. Dulera (Merck), a combination of Mometasone Furoate  (the main ingredient of the inhaled steroid Asmanex available since 2005) and Formoterol Fumarate (main ingredient of the LABA, Foradil available since 2001). Dulera is indicated for the treatment of asthma in ages 12 and above. It is an aerosol inhaler that has a digital dose counter and comes in two strengths. It is a controller inhaler that should be taken as two puffs twice daily. It should never be used to relieve symptoms. Short acting reliever inhalers should also be on hand for use as needed.