Too Many Asthma Medications?

Folks with asthma are often taking 2 or 3 asthma medications every day, even when they have been in the green zone of good control for many months. Most of the time, they can work with their doctor to successfully discontinue one or two of those expensive medications and remain in good control.

Brooke, a 12 year old girl with mild asthma since age 5 gets a cold in February which "goes to her chest," causing coughing spasms followed by wheezing and shortness of breath, relieved by her albuterol rescue inhaler. During the next 3 days her asthma does not improve and she requires albuterol every 4-6 hours. So her mom takes her to the pediatrician in their Dallas suburb. She hears wheezing, measures a peak flow of 60% of predicted, and agrees that Brooke's asthma is worse (into the yellow zone of poor control) and prescribes a new inhaler (Advair) to take twice every day, and a once-a-day pill (Singulair). Brooke's asthma improves over the next few weeks, so that she no longer needs to take the albuterol inhaler, except during soccer practice. Brooke's mom realizes that the new asthma medications are working great, so she encourages Brooke to take them faithfully every day, and it becomes part of her daily routine. Three months later, when Brooke returns to the pediatrician for an ear ache and leg cramps, no wheezing is heard and her peak flow is 120% of the predicted value.

Ever since her asthma exacerbation, probably due to a rhinovirus, Brooke has been taking 3 different types of asthma controller medications: fluticasone (an inhaled corticosteroid), salmeterol (a long-acting bronchodilator), and montelukast (a leukotriene inhibitor). The Advair inhaler contains the fluticasone (at one of 3 different doses, depending on which was prescribed) and the salmeterol. What Brooke, her mom, and the pediatrician don't realize is that Brooke's leg cramps are almost certainly due to a side-effect of the salmeterol. Furthermore, she probably no longer needs the salmeterol (which is also causing insomnia, but nobody asked Brooke about her sleep). She probably also no longer needs the Singulair, and may not even need a moderate daily dose of fluticasone (which was causing a mild sore throat due to thrush, but the pediatrician was too busy to look behind her tongue to see the white fur at the back of her throat).

Patients are naturally more likely to go to a doctor when their asthma becomes bothersome, and their doctor is naturally likely to respond to the asthma exacerbation with drugs that are highly likely to work well for the majority of patients. This "step-up" in therapy is recommended by widely accepted clinical practice guidelines (published by the NAEPP). However, these guidelines also recommend a step-down in asthma therapy after the asthma is well controlled for 2-3 months. Unless the patient just decides to stop one or more of the asthma medications by themselves (without consulting a doctor), those with good medical insurance will usually just keep taking the medications. Since the patient no longer has asthma complaints, the doctor may follow the old adage, "If it ain't broke, don't fix it."

The problem is, the Advair inhaler costs $120 per month and the Singulair pills cost 3 dollars each ($90 per month). Even if insurance covers all but the copay for these drugs, this unnecessary cost is borne by someone or "everyone." In addition, the patient suffers from side-effects which are unmentioned or unrecognized (the leg cramps, insomnia, and thrush, for example). Asthma medications should be tailored for each patient, and used only for as long as the benefits outweigh the costs and side-effects. A good written asthma action plan will take these factors into consideration, allowing the patient to step-up and step-down their therapy as guided by their symptom frequency and lung function, but sadly, only a fraction of patients with asthma have been given one. I recommend that you print one from WebMD and take it to your next visit to the doctor. Ask her to complete it for you or your child with asthma. Also ask her if it's really necessary to take all of those asthma medications during the next 3 months, if you continue to stay in the green zone.

Related Topics: Asthma Complexities, Asthma and Allergies

Tags: asthma control, albuterol, Advair, Singulair

Respiratory Therapists, Part II

The keynote speaker at the Respiratory Therapists' conference was Doctor Homer Boushey from San Francisco. He talked about the recent knowledge gained from his participation in several NIH-funded, multicenter clinical trials of asthma therapy. He was the first author of a rather shocking paper published in the NEJM this year showing that many patients with mild asthma can be successfully managed with a couple of prednisone bursts each year (during exacerbations) instead of daily inhaled corticosteroids (the treatment recommended by current clinical practice guidelines) He concluded his talk to about 2000 RTs in the audience that asthma treatment in the near future will be optimally tailored to each individual patient.

I gave a talk introducing RTs to the measurement of exhaled nitric oxide for confirming the diagnosis of asthma, predicting those patients who will respond to inhaled corticosteroid (ICS) therapy, and for titrating the daily dose of ICS medications. A free forum for local residents of San Antonio with lung diseases provided spirometry and pulse oximetry testing, a sampling of inhaler and oxygen delivery devices, and the opportunity to talk with a pulmonary specialist or RT about their lung disease and treatments. I had prepared a presentation of asthma FAQs from my WebMD experience, but instead spent my 20 minutes answering the questions of ten of the patients in the audience.

I was surprised by their rather rare lung diseases, including sarcoidosis, alpha-1 antitrypsin deficient COPD, idiopathic pulmonary fibrosis, and pulmonary vascular disease.

Abstracts of clinical research done by the RTs included one from Toledo, Ohio showing how asthma education reduces ER visits and hospitalizations; one from Vietnam demonstrating the value of spirometry for asthma management; one from Durham, North Carolina showing the wide variation in peak flow values obtained using 5
different brands of peak flow meters; and several demonstrating reduced overall costs of nebulizer treatments in their hospital from switching patients from generic racemic albuterol treatments given every 3-4
hours to Xopenex (L-albuterol) given by nebulizer given every 8 hours, despite the higher cost of Xopenex (two dollars per dose versus 30 cents for albuterol).

I look forward to meeting with the RTs again next December, in Las Vegas. Meanwhile, I will meet with their respiratory technologist cousins in the United Kingdom in January,
and in Australia in March, urging the three societies to share resources.

Related Topics: Asthma Illustrated Guide, Managing Exercise Induced Asthma

Tags: AARC,ANZSRS,ARTP,asthma,research

Respiratory Therapists

I just returned from the annual meeting of respiratory therapists (RTs) in San Antonio. RTs are the professionals who traditionally work with pulmonary specialist physicians caring for
hospitalized patients on mechanical ventilators and those needing breathing treatments. However, during the last decade, RTs have expanded their roles to providing a broad spectrum of outpatient
services for patients with many types of lung diseases. A primary care physician can directly ask the RT for help with these services, including pulmonary rehab, smoking cessation, asthma education, spirometry, long-term oxygen therapy, and home monitoring and treatment for sleep apnea.

If you are new to a community and have asthma or COPD and want to know the best pulmonary specialist for your care, I think that a local RT will steer you to the best pulmonologist, based on their experiences with most of the doctors in your new community. RTs are easily found by going to your local hospital and asking for the RT department (often in the basement, because that's where the ventilators were traditionally stored).

Related Topics: COPD Treatment, Asthma May Raise Risk of COPD, Emphysema

Tags: asthma,COPD,respiratory therapy

Chronic Cough Workup, Part III

Eosinophilic bronchitis (EB) is an airway inflammation affecting all sizes of airways, which causes a chronic cough, but no wheezing. It is distinguished from asthma and cough variant asthma by normal spirometry tests (always) and a negative inhalation challenge test , although sputum tests and eNO demonstrate an eosinophilic airway inflammation. Cough reflex sensitivity is normal in patients with EB.

Inhaled corticosteroids effectively suppress the superficial airway inflammation of EB, but unlike typical asthma, bronchodilators such as Albuterol are not helpful (because such patients have no bronchoconstriction). About 20% of patients with EB develop asthma over the years, but this risk may be reduced by inhaled corticosteroid therapy. In others, the EB just resolves by itself.

Atopic cough is a category recently proposed by Japanese investigators. It has all the features of EB except that cough reflex sensitivity (CRS) is abnormally high and antihistamine therapy is usually successful (as with allergic rhinitis), but there is no evidence of allergic rhinitis (hayfever).

Sino-bronchial syndrome (SBS) is a new name for rhinitis causing sinusitis which causes post-nasal drainage (PND) which leads to chronic throat-clearing and cough. Sinusitis can be confirmed by a sinus CT scan, but PND and sinusitis symptoms are usually enough evidence to confirm sinusitis. Many such patients have allergies which affect their nose, but no lower airway inflammation (thus spirometry, MCT, and sputum eosinophil levels are normal). The cough reflex is usually normal. The usual sinusitis treatments are usually beneficial, and chronic erythromycin therapy usually eliminates the chronic cough.

GERD (gastro-esophageal reflux disease) can cause a chronic cough and is increasingly common as people gain weight, but also occurs in thin people and may not cause the classic symptom of heartburn after eating a heavy or spicy meal. The gold standard test for GERD uses a 24 hour esophageal pH probe, but this is expensive and poorly accepted by many patients, so GERD is usually ruled out as the cause of a chronic cough by a 3-6 month trial of a proton pump inhibitor pill (PPI, which eliminates gastric acid production).

Chronic idiopathic cough (CIC) is a category proposed by British investigators in 2005. Idiopathic means that all other causes of a chronic cough have been ruled out, so doctors don't know what's causing it. Such patients have an increased cough reflex sensitivity, as measured by inhalation of increasing concentrations of capsaicin. None of the other tests mentioned above are abnormal. Capsaicin is the "spice" or heat from chili peppers and the principal ingredient of Mace, but the CRS test uses low concentrations and is very safe and well-tolerated by patients. The onset of the chronic cough of CIC is often with a upper respiratory viral infection (URI), but the post viral URI cough of most people resolves within a few days or weeks. Interestingly, the only abnormal test of those with multiple chemical sensitivity is also cough reflex sensitivity.

Chronic Cough Workup, Part I
Chronic Cough Workup, Part II


Related Topics: Asthma Complexities, Coughs: Home Remedies

Technorati Tags: asthma,cough,flu,bronchitis

Chronic Cough Workup, Part II

What follows is a description of the diseases which cause a chronic cough and a summary of how the test results are used to determine the diagnosis and the treatment.

Classic asthma causes intermittent episodes of wheezing with chest tightness, shortness of breath, and cough. When the patient is currently having such an episode, spirometry demonstrates airway obstruction (a low FEV1/FVC) and airflow improves within 15 minutes (FEV1 increases more than 12%) after inhaling a couple of puffs of albuterol (a bronchodilator which is much stronger than caffeine). If the patient has recovered from the symptoms previously experienced, then spirometry may be normal and a methacholine challenge test (MCT) will demonstrate twitchy airways (bronchial hyper-responsiveness, BHR) due to the airway inflammation in the lungs.

Other tests of airway inflammation which help to confirm typical asthma are increased eosinophils (white blood cells which respond to allergens) in the blood and induced sputum, and an increased concentration of nitric oxide in the exhaled breath (eNO >30ppb). Despite a chronic cough, the cough reflex sensitivity (CRS) of patients with asthma is usually normal (although it's rarely measured). The treatments most likely to be effective for asthma are inhaled corticosteroids (ICSs) and long-acting bronchodilators (LABs). Singulair pills (monteleukast) also successfully reduce airway inflammation in about one-fourth of patients with mild asthma.

Cough-variant asthma (CVA, not to be confused with a stroke) is just like mild classic asthma except that nobody has heard any wheezing (yet). All of the lab test results are like classic asthma, but on the average, the results suggest less severe airway inflammation. CVA treatments are identical to those for classic asthma. About one-third of patients with CVA develop classic asthma with wheezing during the next several years. Patients with CVA are often frustrated because they have been told that they don't have asthma because nobody can hear them wheeze and their spirometry test results are usually normal. Read the book "Breathless" by Louise DeSalvo for a typical story of such a patient.

Chronic Cough Workup, Part I
Chronic Cough Workup, Part III

Related Topics: Heartburn and Asthma, Controlling Your Asthma

Tags: asthma,chronic cough,CVA,spirometry

Chronic Cough Workup, Part I

Classic asthma, cough-variant asthma, eosinophilic bronchitis, sino-bronchial syndrome, rhino-sinusitis, atopic cough, multiple-chemical sensitivity, post-viral URI, and GERD can all cause a chronic cough in a non-smoker. The successful treatments differ, so how can a doctor distinguish between them?

An acute cough is defined as lasting less than 3 weeks. A chronic cough has lasted more than 8 weeks (two months). A chronic cough in a cigarette smoker is called chronic bronchitis, and usually disregarded by the smoker. The cure for a smokers' cough is simple, but rarely employed (smoking cessation). The most common causes of a chronic cough in a non-smoker are asthma, rhinitis with sinusitis and post-nasal drainage (PND), and GERD (gastro-esophageal reflux disease). Most people with a chronic cough just try OTC (over the counter, non-prescription) cough remedies, many of which suppress the brain's cough reflex (as do opiates like codeine and morphine), but no OTC medication treats the underlying cause of the cough.

A chronic cough can dramatically reduce the quality of life, so some people seek help from a doctor. The characteristics of the cough (dry or wet) and phlegm (thick, thin, or color) are rarely helpful in the diagnosis, but the factors which provoke the cough (if any have been recognized) may provide a clue. Instead of ordering tests to determine the exact cause of the cough, many primary care physicians will take an empiric approach: treat the most likely cause for a few weeks or months, and if that doesn't work, treat the second most likely cause, and so forth until something seems to work, the cough resolves by itself, or the patient gives up on the process.

When all else fails, patients with a chronic cough may be sent for evaluation by a specialist (pulmonary, allergy, or ENT) who is likely to order tests to determine the exact cause of the cough.

Next in the series: Possible causes for chronic cough

Chronic Cough Workup, Part II
Chronic Cough Workup, Part III


Related Topics: Whooping Cough, COPD

Technorati Tags: asthma,allergies,GERD,COPD,cough