Treating Asthma

Goals of asthma treatment

Many people set their goals for asthma control too low. This may be because people are unaware of what they can expect from treatment or because they have a greater fear of the long-term effects of their medications than they do of the disease. It is important to aim for a high level of control to minimize the degree of irreversible lung damage and the risk of severe, life-threatening exacerbations. Goals for asthma treatment include:

• No or few asthma symptoms during the day, at night and after exercise
• Prevent all or most asthma attacks
• Participate in all activities, including exercise
• Maintain lung function as close to normal levels as possible
• No emergency room visits or hospital stays
• Less need for quick-relief medicines
• No or few side effects from medicines

Medication Treatment

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms. Treatment is approached in a stepwise manner according to the severity of the disease and how well it is controlled.

Quick Relief Medications

Quick relief medications are also commonly called 'rescue medications. They work within minutes to relax the airway muscles, making it easier to breathe. Although these medications temporarily relieve the symptoms of asthma, they do not reduce inflammation in the airways.

Quick relief medications are available in small hand held inhalation devices or in liquid form for use in aerosol machines. Follow the directions included in the package insert, for using your inhalation device. Different types of inhaled medications require different techniques.

Examples of quick relief medications include:

• Short acting beta 2 agonists for inhalation (SABA) (albuterol/salbutamol, levalbuterol, terbutaline and fenoterol)
  Short acting beta2 agonists are the medications most commonly used for quick relief of asthma symptoms and to prevent exercise induced asthma. They relax the airway muscles within minutes and their effects can last for 4 hours or more. Asthma symptoms brought on by exercise can be prevented in more than 80% of patients if they use 2 puffs of their short acting beta2 agonist 5 to 30 minutes before exercise.
• Anticholinergics (Ipratropium bromide-Atrovent®)
  Anticholinergic medications are sometimes prescribed for immediate relief of asthma symptoms in patients who are unable to tolerate the side effects of beta2 agonists. They take a little longer to act but their effects last longer.
• Oral or intravenous corticosteroids (prednisone, methylprednisilone) are useful for preventing and treating acute attacks or severe asthma. The side effects can be significant and may include glucose intolerance, weight gain, mood changes and hypertension when used for short periods. Used for long periods of time osteoporosis, hypertension, cataracts and muscle problems may develop. To reduce the risk of side effects oral corticosteroids are generally used for short periods, such as one to two weeks, or they may be used on an every second day dosing schedule if they have to be used for longer periods.

Long-term control medications

If quick relief medications are required more than twice a week (not including before exercising) an anti-inflammatory medication should be added to treatment to achieve better control. Many of the long-term control medications work by reducing airway inflammation. They cannot be used as rescue medications, but they help reduce the number of times rescue medications are needed. Long-term control medications include:

1. Inhaled corticosteroids
2. Oral corticosteroids
3. Antileukotrienes or leukotriene modifiers
4. Long-acting inhaled beta2-agonists (never taken alone)
5. Cromolyn sodium and nedocromil
6. Methylxanthines
7. Immunomodulators

1. Inhaled corticosteroids (beclomethasone dipropionate, budesonide, fluticasone propionate) Inhaled corticosteroids are the most commonly used long term asthma medication. They work by reducing inflammation and hyper-responsiveness of the airways. They are considered safe, effective and cost-effective. Inhaled steroids have a lower risk for long-term side effects than oral steroids. A common side effect of inhaled steroids is thrush (pharyngeal candidiasis). This can be reduced by rinsing the mouth after use and/or using a spacer device. It may take several days to weeks for inhaled steroids to reach their maximum benefit. The lowest effective dose of these medications should be given daily rather than as needed.

Examples include:

• fluticasone (Flovent Diskus)
• budesonide (Pulmicort)
• triamcinolone (Azmacort)
• alunisolide (Aerobid)
• beclomethasone (Qvar) and others

2. Oral corticosteroids are useful for preventing and treating asthmatic attacks and treating severe asthma. However they are accompanied by short term and long term side effects including hypertension, high blood glucose levels, weight gain, mood changes, cataracts and muscle problems. Side effects can be reduced by using the lowest effective dose, for the shortest effective period and by using an alternate daily dosing schedule, when longer term therapy is required.

3. Antileukotrienes or leukotriene modifiers (LTRAs) (zafirlkast-Accolate and montelukast-Singulair) LTRAs reduce airway inflammation. These medications are sometimes:

• used as an alternative to low-moderate doses of steroid therapy
• added to low-moderate dose steroid therapy when more control is needed, rather than increasing the dose of steroid therapy
• added to treatment when higher doses of inhaled steroids fail to achieve sufficient control over symptoms.

Since montelukast has gone on the market, the following psychiatric symptoms have been added to the list of 'less common side effects' to watch for and report to your physician if they occur.

• 'behavior and mood related changes [agitation including aggressive behavior,temper tantrums in the pediatric population] bad/vivid dreams, depression, feeling anxious, hallucinations (seeing things that are not there), irritability, restlessness, suicidal thoughts and actions (including suicide), tremor, trouble sleeping'

4. Long-acting inhaled beta2 agonists (salmeterol, formoterol) Long acting beta2 agonists reduce asthma exacerbations by relaxing airway muscles for up to 12 hours. They should be used twice daily, morning and evening and are often helpful in reducing nighttime asthma symptoms. Salmeterol should not be used as a 'rescue medication' since it takes too long to exert its effect. Formoterol is sometimes used as a 'rescue medication' and for exercise induced asthma since it is both a long-acting and short acting beta2 agonist.

Long acting beta2 agonists have a black box warning stating they may increase the risk of asthma-related exacerbations and deaths. This problem is believed to be an inflammatory response and the risk is reduced when inhaled steroids are used at the same time. Long acting beta2 agonists should never be used alone, and should only be used in patients already taking inhaled corticosteroids.

Side effects of inhaled beta2 agonists Check with your doctor if any of the following side effects occur:

• cold or flu like symptoms, fever, chills, cough, hoarseness, sneezing, runny nose, sore throat
• body aches or pains, headache
• chest pain, chest discomfort or chest tightness, fast or pounding heartbeat
• congestion, cough with mucous
• difficulty breathing, shortness of breath, wheezing, loud, high-pitched breathing
• dry throat
• pain or tenderness around the eyes or cheekbones
• swollen glands in the neck
• trouble swallowing, hoarseness, choking
• rash, hives, swelling of the face, throat, tongue, lips, eyes, hands, feet, ankles, or lower legs

5. Cromolyn sodium and nedocromil - These inhaled medications are used less commonly since more effective inhaled corticosteroids have come on the market. They have few side effects, but must be used regularly to provide ongoing protection.

6. Methylxanthines-Theophylline Products - theophylline, oxtriphylline and aminophylline)
Oral theophylline products are considered a third-line therapy, primarily because of their toxicity and mild bronchodilator activity. Their dose should be increased slowly to minimize side effects and blood levels should be monitored to avoid toxicity. They interact with a wide variety of medications. For instance cimetidine, erythromycin, quinolones and verapamil may increase theophylline levels, while rifampin, carbamazepine and phenytoin may decrease their blood levels.

Side effects of theophylline products

If side effects become severe or do not go away you should contact your physician. Possible side effects of theophylline include:

• upset stomach, stomach pain, diarrhea
• headache
• restlessness, insomnia, irritability

Call your doctor immediately if you experience any of the following side effects:

• vomiting
• increased or rapid heart rate, irregular heartbeat
• seizures
• skin rash

7. Immunomodulators - Omalizumab (Xolair)
Omalizumab is a monocoloal antibody that works on the body's immune response system. It is administered by subcutaneous (under the skin) injection once every 2 to 4 weeks. It has been approved for use in adults and children over twelve years old and is primarily used to treat severe or difficult to control allergic asthma.

There is a risk of anaphylaxis in about 1 in 1000 people who use omalizumab. Health care providers should monitor patients (in their office) for signs of anaphylaxis, for period of time following the injection. Get emergency medical treatment right away if you have signs or symptoms of anaphylaxis after receiving omalizumab.

Signs and Symptoms of anaphylaxis include:

• wheezing, shortness of breath, cough, chest tightness, or trouble breathing
• low blood pressure, dizziness, fainting, rapid or weak heartbeat, anxiety, or feeling of ?impending doom?
• flushing, itching, hives, or feeling warm swelling of the throat or tongue, throat tightness, hoarse voice, or trouble swallowing

Side effects of omalizumab
Possible side effects of omalizumab injection include:

• pain, redness, swelling, warmth, burning, stinging, bruising, hardness (bump), or itching at the injection site
• joint pain in the arms and legs
• tiredness
• ear pain
• may increase the risk of developing cancer of the breast, skin, salivary gland or prostate
• anaphylaxis