Review Article
Asthma controller therapy during pregnancy

https://doi.org/10.1016/j.ajog.2004.07.056Get rights and content

Objective

This study was undertaken to educate physicians on the safety of asthma controller use during pregnancy.

Study design

A comprehensive literature search using MEDLINE, the Cochrane Controlled Trials Register and Database of Systematic Reviews, EMBASE, and selected bibliographies identified human gestational studies of asthma controller medications from which maternal and fetal outcomes were obtained. The US Food and Drug Administration (FDA) pregnancy category ratings were identified from product package inserts.

Results

Human gestational studies were identified for the inhaled corticosteroids (ICSs) beclomethasone, budesonide, and triamcinolone and for cromolyn sodium, theophylline, and salmeterol. Human pregnancy data support an FDA Pregnancy Category B rating for budesonide. Pregnancy Category B ratings for cromolyn, nedocromil, montelukast, and zafirlukast are based primarily on safety in animal reproduction studies. ICSs other than budesonide, theophylline, zileuton, and long-acting β2-adrenergic agonists are Pregnancy Category C.

Conclusion

Human pregnancy data for many asthma controllers are lacking; nonetheless, data support a range of choices among medications rated Pregnancy Category B.

Section snippets

Material and methods

Published English-language studies of asthma controller medications in pregnant patients were identified through searches of MEDLINE (1966-February 2003), the Cochrane Controlled Trials Register and Database of Systematic Reviews (1988-February 2003), and EMBASE (1988-February 2003). An updated search of MEDLINE through June 2004 was also conducted. Classes of asthma controller medications (ie, inhaled corticosteroids [ICS], leukotriene modifiers, and long-acting β2-adrenergic agonists) and

Inhaled corticosteroids (ICS)

According to the NAEPP, ICS, because of their anti-inflammatory action, are the most effective class of asthma controller medications15, 18 and the preferred long-term controllers for persistent asthma of all severities in adults and children. Moreover, studies have shown that ICS significantly reduce the risk of an acute asthma exacerbation when used throughout pregnancy24 and significantly reduce the rate of asthma-related readmissions for pregnant women when used after discharge from the

Comment

Pregnancy category ratings for asthma controller medications are shown in Table VI. Medications rated Pregnancy Category B include nedocromil, cromolyn, and the leukotriene modifiers, montelukast and zafirlukast. Among ICS, only inhaled budesonide is rated Pregnancy Category B. Other ICS, along with theophylline, zileuton, and long-acting β2-adrenergic agonists, are rated Pregnancy Category C.

In a joint position statement published in May 2000, the ACOG and ACAAI recommended ICS as first-line

Conclusions

Uncontrolled asthma in pregnant women can result in perinatal complications and exacerbations, which can be life-threatening for the mother and fetus. Because these risks are greater than those of adverse effects because of controller medication use, women with asthma should receive controller therapy during pregnancy. Although recommendations from the ACOG and ACAAI can serve as a basis for prescribing asthma medications safely during pregnancy, new safety and efficacy data must be considered

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    Supported by AstraZeneca LP, Wilmington, Delaware. Research funding was also received from Genentech, GlaxoSmithKline, Novartis, and Sepracor (J.C.G.).

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