Saturday, September 7, 2013

Intermittent Use of Inhaled Steroids for Mild Asthma

For decades now, guidelines for asthma care have recommended that persons with persistent asthma should take daily anti-inflammatory medication, preferably an inhaled steroid, to lessen their symptoms of asthma and reduce the frequency of flare-ups of their disease (asthma “attacks”).  At the same time, it has been suggested that persons who have very mild disease and few symptoms (“intermittent asthma”) can use their quick-relief bronchodilator as needed and need no other medication for their asthma.  Inhaled steroids have not been recommended for persons with mild and intermittent asthma because: 1) infrequent symptoms do not seem to warrant daily medication, and 2) evidence indicates that long-term use of inhaled steroids does not improve lung function over time or affect long-term outcomes in asthma.

Panels of experts write the asthma guidelines based on their experience and available scientific information.  (The guidelines are not divinely inspired or carved in stone tablets!)  Asked to define “persistent asthma,” the experts reached the following consensus: anyone who has two days or more of asthma symptoms each week or wakes up two or more times with asthma symptoms each month or has lung function that is below normal or has had two or more attacks of asthma (requiring oral steroids) in the past year.  Taken as a whole, patients with persistent asthma who are treated with regular (daily) inhaled steroids have fewer symptoms of their asthma, less need for their “rescue” bronchodilator, better lung function, fewer asthma attacks, and an overall improved sense of well-being. 

But a fair question – and one that has now been addressed by recent clinical research – is exactly where one should draw the line between “intermittent” and “persistent” asthma.  Did the experts get it right, or are there patients with persistent (as defined above) but mild asthma who do not in fact need to take an anti-inflammatory medication daily for relief of symptoms and prevention of asthmatic attacks?  If you have mild persistent asthma and your symptoms are sufficiently few (more than two days out of the week but less than every day), prior asthma attacks have been sufficiently rare, and breathing tests are for the most part normal, might you take inhaled steroids only during periods when your asthma is troublesome but stop them during times when your asthma is no longer bothering you?  It is very likely that many patients with asthma have been following this practice for years – because daily medication use can be onerous – but is it safe and advisable?

Two studies – one in adults [Boushey et al., New England Journal of Medicine 2005; 352:1519] and one in young children [Zeiger et al., New England Journal of Medicine 2011; 365:1990]  – have indicated that the strategy of using inhaled steroids intermittently, only during periods of increased symptoms, is indeed safe for persons with mild persistent asthma.  These studies found that among persons with mild persistent asthma there was no difference in the frequency of asthma attacks, including severe or dangerous attacks, and very little overall difference in sense of well-being whether they used their inhaled steroids every day vs. used them only when symptoms became troublesome … as long as everyone had a plan regarding how to deal with an asthma attack. 

Let’s be specific.  Based on these recent studies, if your asthma has been mild, your medical provider might prescribe for you an albuterol (ProAir, Proventil, or Ventolin) or levalbuterol (Xopenex) inhaler to use whenever you need it.  If you find yourself using your quick-relief bronchodilator a lot, or if you feel congested at the start of a “cold,” or if you are visiting your in-laws who own a cat to which you are allergic, you would begin your steroid inhaler, such as fluticasone (Flovent), budesonide (Pulmicort), beclomethasone (Qvar), mometasone (Asmanex), or ciclesonide (Alvesco).  You would probably take at least four inhalations morning and night every day for approximately ten days, and then when you felt better, didn’t need your rescue bronchodilator so often, had gotten over the cold, or were no longer exposed to the pet cat, stop your steroid inhaler.  And you would be prepared with the knowledge that if your symptoms worsened despite taking the inhaled steroid, you would need to begin oral steroids (e.g., prednisone or Medrol) and be in contact with your healthcare provider.

Two important caveats before one puts this approach into practice.  First, it is not intended for persons with more severe forms of asthma.  Our emergency departments routinely treat persons with asthma who had been doing well until they stopped taking their preventive asthma medication (their inhaled steroids), thinking that they no longer needed them, and then developed severe asthma symptoms.  In persons with moderate and severe persistent asthma, evidence is unequivocal that reducing the dose and then stopping inhaled steroids is associated with more asthma attacks and worse asthma control.  Second, intermittent use of inhaled steroids does not mean “as needed” or “p.r.n.”  For this new strategy to work, the inhaled steroids need to be taken not here and there trying to relieve symptoms but every day, usually twice a day, for a period of 1-2 weeks or more.  Intermittent use of inhaled steroids refers to regular, daily administration, but for a limited period of time rather than year-round indefinitely.

In the future, another group of national and international asthma experts will write an updated set of asthma guidelines and render its opinion regarding this approach to asthma care.  In the meantime, our opinion is that this is a safe and reasonable way to treat mild asthma.  It is not appropriate for persons whose asthma is more severe, and its implementation requires careful explanation and reinforcement such that everyone is clear as to when to begin the inhaled steroids, how to use them and for how long, and what to do if asthma fails to improve as expected.

16 comments:

  1. Asthma and Allergies are different, though they may have related reactions and some of the body’s chemicals that are involved in allergies are also involved in asthma.
    You may need medications to treat allergies or asthma, especially if your symptoms become severe at times. However, recognizing and avoiding the allergic substances that trigger your symptoms is the most important step you can take.

    ReplyDelete
  2. I had asthma growing up but I grew out of it luckily. There are new discoveries now though, you should look into asthma clinical research trials at ocresearch.com.

    James

    ReplyDelete
  3. I am John Smith. I was suffering from severe chronic asthma since many years. I consulted many doctors but in vain. Recently, one of my friend gave me a reference of this society specially dedicated to the patients suffering from asthma, Columbus Asthma Society. I consulted their main doctor Dr. Summit Shah and now I am recovering rapidly owing to their allergy shots. I would strongly recommend you guys to check Columbus Asthma Society and get the best treatment for all asthma related problems.

    Reference: ColumbusAsthma.com

    ReplyDelete
  4. Thanks for giving nice tips for reducing asthma attacks. It would be more helpful if it contains medication treatment tips. One of my friend using Ventolin Inhaler Generic for her asthma attack. Her doctor was recommended this Inhaler to her. It worked very well for her. I definitely recommend it, but not without consulting your doctor.
    Thanks

    ReplyDelete
  5. nice post
    http://mymexicandrugstore.blogspot.ae/2013/08/buy-online-asthma-medicines-mexico.html

    ReplyDelete
  6. I am truly blissful to hear this great truth and trust from an accomplished Manufacturer
    And Exporter Of Pharmaceutical Products
    . What's more your remark truly provided for me trust and courges to do all my best in my study.

    ReplyDelete
  7. your blog post is very nice and thanks to inform. we provide asthma treatment as a albuterol inhaler.

    ReplyDelete
  8. Asthma is treated with the help of albuterol salbutamol. It is best inhaler which is used by many people and they got better results. salbutamol asthalin inhaler if you take it begins working in 2-3 minutes. But for some patients it need to be taken by consulting with doctor.

    ReplyDelete
  9. It is a great information. Now, Asthma is a decease which can be treated. Today, lots of medicines are available in the market and few companies provides online services for delivering medicines.
    Herbal Care 99 is also one of those companies. It provides medicines fully made from herbs.
    Buy Asthma Medicine Online

    ReplyDelete
  10. Nice blog. It has a great information about the Asthama treatment. It is a problem related breath. Lots of treatment also available at this time.
    Asthalin HFA Inhaler is also a good inhaler for ashtma.
    Suminat Nasal Spray

    ReplyDelete
  11. HOW I WAS CURE WITH HERBS
    My name is Mrs Tina Jose am from Mexico I
    have been suffering from asthma , i was leaving with it for years with
    inhaler but all I ever wanted was to get rid of it permanently until i
    was directed to Dr Okosun for herbal mixture he helped me with it then i
    took it for just one week now am physically fit all thanks to him he is
    one of the best herbalist if you have any similar health problem like
    asthma,diabetes, stomach ulcer and some other S.T.D contact him today on
    email okosunjustice909@gmail.com

    ReplyDelete
  12. Thanks for sharing this extremely informative article on best inhaler for asthma. I recently read about some inhaler on website called breathefree.com. I found it extremely helpful.

    ReplyDelete
  13. Thanks for sharing this extremely informative article on best inhaler for asthma. I recently read about some inhaler on website called breathefree.com. I found it extremely helpful.

    ReplyDelete
  14. As a sign of gratitude for how my husband was saved from asthma , i decided to reach out to those still suffering from this.
    My husband suffered asthma and it was really tough and heartbreaking for me because he was my all and the symptoms were terrible, we tried various therapies prescribed by our neurologist but none could cure him. I searched for a cure and i saw a testimony by someone who was cured and so many other with similar body problem, and he left the contact of the doctor who had the herbal cure to asthma . I never imagined asthma has a cure not until i contacted him and he assured me my husband will be fine. I got the herbal medication he recommended and my husband used it and in one months he was fully okay even up till this moment he is so full of life. asthma has a cure and it is a herbal cure contact the doctor for more info on drwilliams098765@gmail.com on how to get the medication. Thanks for reading my story

    ReplyDelete