One can quickly see the potential for confusion. “Which inhaler did the doctor say I should take every day, which one only when I was short of breath or wheezing?” The two inhalers may look virtually identical, except for color. For other people, the complexity relates to two different types of inhalers. In the U.S. all of our quick-relievers come in the form of metered-dose inhalers – a metal canister in a plastic holder from which a short “puff” of medication is released. However, the controller inhalers may take the form of dry-powder inhalers, which require a forceful inhalation to pull the powdered medication from its canister. Then there is the issue of frequency of use: most controller inhalers are meant to be taken once or twice a day and no more; the quick-reliever can be used up to four times a day and even more often in an acute crisis.
What
if ….? What if there were one inhaler
that could be used both as a controller and as a quick-reliever, for
maintenance and for rescue? One device,
one technique to be mastered in order to inhale the medication optimally. Use it once or twice to a day to keep your
asthma quiet, use extra doses from the same inhaler if you find yourself short
of breath or wheezing. Such an inhaler,
containing a combination of two medications, is available … although in the
U.S. it is not recommended for use in this way … yet.
What
made this single inhaler for both maintenance and rescue possible was the
development of a bronchodilator that both exerts its effect quickly (within 3-5
minutes) and also maintains its effect all day (or night) long. This medication is the long-acting
bronchodilator, formoterol, which works for at least 12 hours to hold open the
bronchial tubes, but with an additional dose acts as a quick-reliever. It is combined with an inhaled steroid in the
two inhalers, Symbicort and Dulera.
Symbicort combines formoterol with the anti-inflammatory steroid,
budesonide; Dulera combines formoterol with the anti-inflammatory steroid, mometasone.
Taken
every day, these combination steroid/long-acting bronchodilator inhalers can
keep asthma under good control. If
asthma flares up, additional doses provide quick relief and at the same time
escalate the amount of controller medication, until asthma again quiets. A recent study published in Lancet Respiratory Medicine confirmed
prior reports that this approach is effective and, in the long run, may help to
keep the dose of inhaled steroids as low as possible, which is a good thing.
So
why have U.S. physicians not embraced this approach? First and foremost is the lingering concern,
previously discussed in this blog (see "The Contoversy That Won't Go Away"), that in some patients long-acting bronchodilators like formoterol
may on rare occasion lessen asthma control and cause severe, even fatal asthma
attacks. Although some would argue that
the long-acting bronchodilators are potentially dangerous only when used
without an accompanying inhaled steroid, definitive research to test this
hypothesis is currently being conducted and the results are years away. Other concerns relate to potential side
effects from overuse of a long-acting bronchodilator: if jitteriness or heart racing develops, the
side effect will likely last for many hours.
We
do not anticipate that practice will change in the U.S. any time soon. For now, we are committed to two separate
inhalers: one used regularly for control of asthma; one taken as needed for
quick relief of troublesome symptoms.
But depending on the results of current research into the long-term
safety of long-acting bronchodilators when combined with an inhaled steroid, a
small revolution in asthma care may be coming down the road.
