• Inhaler use may not improve asthma in long term

    January 2008 

    A recent study published in the New England Journal of Medicine provides strong evidence that steroidal inhalers control symptoms of asthma in toddlers but do not change the natural history of the disease. The study, funded by the National Heart, Lung, and Blood Institute, studied 285 preschool children, age 2 to 3, with asthma for two years.

    Researchers found that after two years of treatment with inhaled corticosteroid therapy, asthma symptoms or lung function during the third, treatment-free year was not changed. The researchers concluded that there is not a disease-modifying effect (asthma in later years is not affected) associated with inhaled corticosteroids once the treatment has been discontinued.

    “Many physicians have recommended long-term treatment with steroidal inhalers in an attempt to reduce asthma in the long term.”

    With many physicians recommending long-term treatment with steroidal inhalers in an attempt to reduce asthma in the long term, this study may alter how young children are treated.

    Asthma prevalence among children

    The American Lung Association estimates around four million children under the age of 18 have had an asthma attack in the past year. The association posits there are many other children who have undiagnosed asthma. Among chronic diseases, asthma has become the most common cause for missing school. Although there is no “cure” for asthma, it is a very treatable disease.

    Chronic airway inflammation

    Asthma is caused by chronic inflammation in the airways. This inflammation leads to airway edema (swelling of the lining of the bronchial tubes), mucus secretion into the airway and bronchospasm (tightening of the muscles around the bronchial tubes). The combination of airway edema, mucus and bronchospasm results in narrowing of the bronchial tubes which in turn results in the symptoms of asthma such as cough, wheezing, shortness of air or tightness in the chest. In the early stages of asthma, this bronchial obstruction is reversible. In the case of chronic asthma, these changes may become more permanent and not get better even with treatment.

    It is uncertain what causes asthma but some of the things that can cause inflammation and lead to asthma include:

    • Inhaled allergens such as dust mites, pollens or animal dander.
    • Genetic tendencies - asthma may be inherited.
    • Irritants such as tobacco smoke or air pollution.
    • Weather - typically changes in temperature, humidity or cold air.
    • Strong emotions.
    • Exercise - 80 percent of people with asthma experience narrowing of airways with strenuous exercise.

    These items are often referred to as asthma triggers. It is important to note that although asthma and allergies are often equated as the same, they are very different. To be diagnosed with asthma there must be inflammation in the airways. A large portion of patients who have asthma do have an allergic tendency, but not all patients. In children, viral infections and exercise are more common triggers.

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Page last updated: 8/7/2015 2:16:48 PM
  • What the news means for you

    Inhaled steroids still most effective asthma treatment

    Jamshed F. Kanga, MD
    Pediatric pulmonologist

    Wright, Heather, MDAlthough the study mentioned here outlines some interesting questions about the use of long-term inhaled corticosteroids in preschool children, there are no immediate plans to change the current treatment guidelines. Asthma is a serious disease and children with chronic asthma should be on controller therapy. Most experts agree that inhaled steroids are the most effective treatment for chronic asthma. The question we don’t yet know the answer to is whether treatment for a long period of time will result in the disease being cured.

    “Most experts agree inhaled steroids are the most effective treatment for chronic asthma.” 

    Diagnosing asthma

    Children are quite unique in that the diagnosis of asthma can be difficult due to the fact symptoms of viral infection in young children are very similar to asthma. If the symptoms become more chronic and persistent, then the diagnosis of asthma should be considered.

    Treatment options

    Once the diagnosis of asthma is clear, it needs to be controlled and treated to prevent damage to the airways. Asthma medication falls into two groups:

    (1) rescue or reliever medication and
    (2) controller medication.

    Rescue medication is a temporary treatment and does not address inflammation in the airways. These medications are taken at the first sign of asthma symptoms, such as wheezing. Rescue medications work quickly to relax muscles surrounding the airways making it easier to breathe almost immediately. If needed, rescue medications are sometimes taken before exercise to help prevent asthma symptoms. The most common rescue medication is albuterol. Other familiar names include Maxair®, Proventil®, Ventolin® or Xopenex ®.

    The second type of medication, controller medication, addresses inflammation in the airways. These medications are used every day in an effort to keep asthma under control. When taken daily, controller medications reduce inflammation in the lungs, helping to reduce and even prevent symptoms of asthma. Inhaled corticosteroids, the same drug tested in the recent study published in the New England Journal of Medicine, are a common controller medication. Leukotriene modifiers, mast cell stabilizers and long-acting bronchodilators are also examples of controller medications.

    Inhaled corticosteroids - risks, benefits, alternatives

    The best medications we have to treat chronic asthma are inhaled steroids. Although there is a lot of concern that in children long-term steroid use leads to a decrease in growth, most experts agree the benefits outweigh any potential short-term growth decrease. Most of the three- to five-year studies show only a slight growth difference. That difference often disappears as the child ages.

    The particular study mentioned here showed the placebo group was 1.1cm taller at 24 months, but by the end of the trial, the height difference was only 0.7cm. Although it doesn’t receive as much attention as growth, the most common side effect of corticosteroids is oral thrush infection. However, with the use of proper spacers and regular teeth brushing, this side effect is easy to prevent.

    Minimizing side effects

    Companies have now started developing nonsteroidal controller medications, such as Singulair®. We still don’t have enough data to determine if they are better than corticosteroids but they do provide an alternative. If growth is a concern, it is also possible to lower the dose of the steroid. In our clinic, all patient heights are monitored closely. If a child is in good control, we always try to cut back the dose of their inhaled steroid.

    We attempt to optimize treatment by monitoring the inflammation of the airways with a regular (every three to six months) lung function test. Spirometry is a simple lung function test that can be performed on children older than 5 years. A nitric oxide monitor is another way to measure inflammation in the airway to help ensure the patient is receiving the correct dose of steroids and thus the optimal treatment.

    “Asthma is still under underdiagnosed and often inappropriately treated.” 

    Future of asthma treatment

    The prognosis of childhood asthma is not known. We once thought children would “outgrow” their asthma; however long-term follow-up has shown that many childhood asthma patients continue to have asthma as adults.

    The study mentioned here was a good study and provides some much needed insight into the effect of asthma therapy once it is discontinued.  Longer studies are needed to address this important question of whether treatment helps with long-term obstruction.

    It is important to remember asthma is still under underdiagnosed and often inappropriately treated. To optimize your treatment, talk with your doctor about appropriate medications. We want every child to be able to live a normal life and participate in sports. We have very good medications available today and most children with asthma can lead a very normal life.

    Dr. Kanga is a pediatric pulmonologist at Kentucky Children’s Hospital and a professor of pediatrics and chief of pediatric pulmonology at UK College of Medicine.

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