Lessons Learned

The federal government’s Centers for Disease Control recently released statistics on the rates of current cigarette smoking among high-school students and adults in the United States.  The news was good: the percentage of high-school students (19.5%) and adults (19.3%) who are currently smoking cigarettes reached the lowest levels in 45 years. Given that in the U.S. cigarette smoking is the number one preventable cause of respiratory illness and death, this news is good for the health of the nation.

From the perspective of those with asthma, it is particularly encouraging. Cigarette smoking and second-hand cigarette smoke exposure are associated with worse symptoms of asthma. Cigarette smoking during pregnancy is thought linked to an increased risk that the newborn will develop asthma (and other respiratory illness). Cigarette smoking predisposes to respiratory tract infections that provoke asthmatic attacks. When parents stop smoking or smoke only outside of the home, children with asthma breathe better.

Why is it that fewer Americans are taking up cigarette smoking and more are quitting, despite billions of dollars spent by the manufacturers of cigarettes to encourage smoking? There is no single reason. In our opinion it is the combination of all anti-smoking efforts taken together that have successfully turned the tide. Each component of the anti-smoking campaign contributes: smoking bans in public places; cigarette taxes that drive up the cost; media campaigns vividly portraying the devastating consequences of emphysema, lung cancer, throat cancer, etc.; physician training in smoking cessation counseling; free community-based smoking cessation programs; and others. All together these efforts are slowly but steadily working to counter the powerful addictive allure of cigarette smoking.

We think that there is a lesson to be learned for treating and ultimately curing asthma. A single intervention that prevents its development or cures asthma in those living with the disease seems unlikely anytime soon. But multiple groups of scientists working together to understand the key processes involved in asthma; clinicians seeking better treatment strategies; pharmaceutical companies pursuing newer, safer medications; advocacy groups focusing attention on the importance of the disease; educators sharing information on the knowledge, skills, and attitudes needed to manage asthma effectively; local, state, and national asthma disease prevention and control programs working to create innovate programs, including promotion of healthier home and work environments; and patients and families helping other patients and families – these are some of the elements of a multi-pronged effort that will ultimately reduce asthma suffering and the risk of asthma attacks and death. Collaboration and sharing are key.

And the pay-off is not a remote pipedream. Already there is cause for encouragement. Although the number of persons in the U.S. with asthma remains high and is perhaps still on the rise, the number of persons hospitalized with asthma attacks or dying from asthma has been steadily decreasing for the last 10 years. Better care and better outcomes are realities within reach.

Are Allergies Contributing to My Asthma?

Studies demonstrate that at least 60% of adults with asthma and 80% of children with asthma are sensitized to one or more common environmental allergens. But what is allergic sensitization, and how might being allergic to something contribute to asthma?


Allergies are the result of the immune system, a complex and diverse group of cells in the body, many of which start of in the bone marrow, then circulate in the blood as white blood cells, and eventually leave the blood to enter body tissues like the lungs and the gastrointestinal tract. It is believed that the immune system’s main function is to defend the body against danger. Most often, that danger is from infection – the invasion of the body by micro-organisms like bacteria, viruses, parasites, and fungi. The immune system is not only like a combined armed forces, police, and fire department (defending the healthy “citizens” of the body), but also a like a border guard, checking the identity of things that enter into the body every day when we breath, eat, and drink – weeding out the “terrorists” from the “tourists.”

Although a precise understanding of the molecular and cellular details is incomplete, a popular hypothesis is that allergies result when the immune system mistakenly identifies a harmless substance (such as dust mite or cat dander protein) as if it were dangerous. The immune response against these substances constitutes an allergic reaction. Among the many cells involved in such reactions, the mast cell is a powerful central player in allergies. Armed with claw-like molecules called “IgE antibodies,” mast cells in the airways can bind to allergenic proteins, which triggers the release of mast cell inflammatory chemicals like histamine, leukotrienes, and cytokines that bring about many of the features of asthma. Mast cell activation by allergens can lead to airway spasm (bronchoconstriction), mucus hypersecretion, and the influx of other inflammatory cells such as eosinophils. This allergic inflammation results in asthma symptoms like wheezing, cough, and breathlessness.

Allergies such as “hay fever” (known in medical parlance as “allergic rhinitis”) are common. Knowing whether allergies contribute to asthma can be an important part of prevention and treatment. If allergies are part of what drives your asthma, avoidance of allergic triggers, treatment with allergy medications, and the use of allergy immunotherapy (“allergy shots”) to reprogram the immune system away from its mistaken attack against common harmless substances may help. Allergy testing –blood testing or skin testing – in conjunction with a careful history and physical exam at a visit with an allergist can answer the question of whether or not allergies are contributing to your asthma.

Long-Acting Beta Agonists (LABAs) - Why All the Fuss?

Every package insert of a medication containing salmeterol (Serevent) or formoterol (Foradil), including the very popular and effective bronchodilator-steroid combinations, Advair, Symbicort, and Dulera, includes a black-box warning about serious potential risks from these long-acting beta-agonist bronchodilators. In persons with asthma, the warning notes, use of these medications is associated with an increased risk of death and near-death (requiring ICU care) from an asthma attack.


Therein lies a major dilemma. Highly effective medications used to control asthma, recommended by national and international panels of experts in their Guidelines for optimal management of asthma, may pose a risk of causing a fatal or near-fatal asthma attack. Why do we say “may” pose a risk? Evidence from a large study (26,000 subjects) indicated an increase in asthma deaths and near-fatal asthma attacks among persons treated with salmeterol compared to placebo, but it did not control what other medications persons participating in this study were taking. Most of the subjects were not taking an inhaled steroid. It is well accepted that a long-acting beta agonist without a medication to control the inflammation of the bronchial tubes in asthma is a bad idea. But what about patients who take an inhaled steroid (such as those combined with a long-acting bronchodilator in Advair, Symbicort, and Dulera)? Are they then safe from any increased risk of severe asthma attacks?

This question is central to the future of asthma care. The answer is too important to leave to speculation and opinion. So the FDA has mandated that a large-scale study be performed in which all subjects (more than 45,000 to be recruited) will receive an inhaled steroid. In addition, half will also receive a long-acting beta-agonist bronchodilator and half will receive a placebo. Participants will be observed for 6 months to determine whether the two groups have any differences in their rates of hospitalization, respiratory failure, or death from asthma. And then – around 2017 – we will know the answer.

In the meantime, we rely on hunch, intuition, and best guess based on information currently available. Our bias is that the long-acting beta-agonist bronchodilators when used in combination with an inhaled steroid will prove to be safe as well as effective.

P.S. Long-acting beta-agonists in patients with COPD are not associated with any increase in respiratory-related deaths or near-deaths from COPD.

Going Generic

Montelukast (Singulair) is the most widely prescribed leukotriene blocker in the United States. It is used to treat both asthma and allergic rhinitis and is approved for both very young children and for adults. It has been a mainstay of asthma and allergy treatment since first approved by the Food and Drug Administration (FDA) in 1998 … and it is costly! On average, a one-month supply costs approximately $150 or as much as $5 per tablet.  Financial relief may be on the way. The US patent for Singulair expires in August of this year, and it is very possible that a generic version of montelukast will be made available soon thereafter.

In general, manufacturers of generic medications are able to sell their medications at a lower cost than the original brand-name version.  The FDA is charged with ensuring that the generic medications are equally effective and safe as their brand-name predecessors.  This past year has seen approval of generic atorvastatin (Lipitor), the cholesterol-lowering medication, and of levofloxacin (Levaquin), a powerful antibiotic. Now, a low-cost generic montelukast may be on its way.

What's our opinion about generics?  In general, we are big fans.  We perceive them as an important way to reduce medication costs, make medications more widely available to those who need them (because of increased affordability), and help reduce the inflated cost of healthcare in America.  True, one may occasionally find that a brand-name version of a medication works better for you or is better tolerated, but that tends to be the exception rather than the rule.  Many, many people miss generic albuterol by metered-dose inhaler, having come to accept the generic version -- when it was still available -- as every bit as good as the branded albuterol inhalers (ProAir, Proventil, and Ventolin). 

On our wishlist: a generic and lower cost inhaled steroid by metered-dose inhaler (such as a generic fluticasone or beclomethasone).  By making inhaled steroids more affordable and thereby more widely used, it would save lives and reduce asthma hospitalizations and emergency department visits across the country.

By way of introduction...

As Partners Asthma Center enters its 22nd year (having begun as the Longwood Medical Area Adult Asthma Center in 1989), it is high time that we enter the modern internet world of social networking and electronic media. Part of our mission has always been to share reliable and up-to-date information about asthma and related diseases with our patients. Via our website – www.asthma.partners.org – we have also made this information available to anyone who wishes to join us online. Now we propose to take the next step, as we launch our Partners Asthma Center Asthma Blog.

Partners Asthma Center is a collaboration of allergists and pulmonologists at Brigham and Women's/Faulkner Hospital, Massachusetts General Hospital, Newton-Wellesley Hospital, and North Shore Medical Center. We are committed to excellence in patient care, research, and teaching about asthma and related diseases.

Where exactly are we hoping to go as we enter the “blogoshere?” We have three goals in mind. The first is rapid dissemination of information, posting new pieces about asthma every week or two. The second is the opportunity for interactive dialogue about asthma. With a few keystrokes on your computer keyboard, you can let us know what you think about our blog or anything else about asthma that you have on your mind. You can share your thoughts with a huge community of people worldwide living with similar medical challenges related to their asthma. And third, we can achieve these first two goals at no cost for printing, mailing, or mailing list management. Quicker, more interactive, open to all, and free… that is the promise of the information highway. To it we hope to bring a reliable source of useful information and trustworthy medical opinion.

So join us as we venture boldly forward: visit http://pacasthma@blogspot.com. Beam us up, Scottie!