Several drug regimens are available for asthmatics, but the key to asthma control is to reduce airway inflammation, and therefore limit the need for short-term rescue medications.
For reasons that aren't clear, the incidence of asthma has been increasing in recent years. According to the Centers for Disease Control, between 1980 and 1996 asthma increased 73.9%, with an estimated 14.6 million people in the United States reporting asthma during 1996, or 55 persons out of each 1,000.
To decrease airway inflammation, asthma symptoms and the risk of death, inhaled corticosteroids should be used daily over an extended period of time. They include Pulmicort (budesonide), Aerobid (flunisolide), Flovent (fluticasone propionate), Azmacort (triamcinolone acetonide), and QVAR (beclomethasone dipropionate). "Inhaled corticosteroids are generally free of serious toxicity, and the risk of systemic effects can be minimized by using the lowest effective dose and using proper inhalation technique to minimize swallowing of the drug," says Mark Abramowicz, MD, editor of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs.
When an asthma attack occurs, short-acting beta2-agonists are used to reduce symptoms such as cough, chest tightness and wheezing. "Asthma is a high-cost malady, and it is difficult to manage," says Mark N. Brueckl, RPh, pharmacy affairs manager for the Academy of Managed Care Pharmacy. "Patients tend to rely on rapid-acting beta2-agonists, the 'rescue medications,' while the true goal of treatment is to achieve stability so they wouldn't have to use them."
"Inhaled corticosteroids, when used appropriately, are very effective, safe medications," Brueckl adds. "Some patients are afraid of them. This may be related to the controversy over misuse of anabolic steroids in athletics. Some patients may be confused and think all steroids are the same."
When asthma symptoms aren't fully controlled by an inhaled corticosteroid, and the patient is using a rescue medication more than twice a week, it is appropriate to add a long-acting beta2-agonist such as Foradil (formoterol) or Serevent (salmeterol). Formulations are available that combine inhaled corticosteroids and long-acting beta2-agonists.
Leukotriene modifiers are oral asthma medications that appear to be less effective than either an inhaled steroid, or an inhaled steroid/long-acting beta2-agonists combination. However, they are useful in patients with prominent exercise-induced symptoms, or those who have difficulty using an inhaler. They include Singulair (montelukast), Accolate (zafirlukast) and Zyflo (zileuton). "Singulair appears to be the safest leukotriene modifier for long-term use, and is less likely to cause drug-to-drug interactions than the other leukotriene modifiers," Dr. Abramowicz says.
Asthma treatment must go beyond medications. Attacks often are triggered by environmental allergens such as mold, pollen, dust mites, cockroaches and animal dander. That means the first step in treating asthma is to clean up the house and select non-allergenic furnishings, to limit environmental triggers as much as possible. Patients need to monitor their own lung function, using a peak expiratory flow meter, to identify constricted bronchial tubes. They need to take appropriate medications before actual symptoms appear.
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