Smokers with asthma: Just Quit!

If you are a smoker with asthma, smoking cessation is better than prednisone

The results of a unique new study done in Glasgow measured improvements in asthma control in adult smokers who decided to quit smoking. Lung function (FEV1) improved by an average of 15% and up to 36% in the ten patients with asthma who quit smoking. These improvements began within a week after smoking cessation and lasted throughout the 8 weeks of the study. This was a much larger improvement than after a 2 week "burst" of prednisone (40mg per day). [see the abstract Chaudhuri R in Am J Respir CCM April 2006]

Previous studies had already shown that 25-50% of adults with asthma are current smokers, and that these people have more severe asthma symptoms, higher rates of emergency room visits and hospitalizations for asthma, more rapid loss of lung function over several years, and respond less well to inhaled corticosteroids (like Flovent, QVAR, and Pulmicort).

This report should prompt smokers with asthma to decide to quit. They will need less asthma medication to achieve better control of their asthma. Some smokers can quit "cold turkey" but others need help from counseling, nicotine replacement therapy, or bupropion (Zyban). This summer, Chantix (varenicline pills) will become available in the United States. Chantix eliminates nicotine cravings, helping about half of smokers to quit successfully. See my recent blog about Chantix.

Related Topics: FDA OKs New Quit-Smoking Drug, Quitting Smoking to Help Your Asthma

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Wheezy Preschoolers

Daily use of inhaled corticosteroids for preschool children with a history of intermittent wheezing does not prevent progression to asthma.

Frequent episodes of wheezing are common in infants and toddlers. These episodes are successfully treated with asthma medications, such as inhaled bronchodilators (albuterol or salbutamol), inhaled corticosteroids (an ICS such as budesonide or fluticasone), and if severe, oral corticosteroids (such as prednisolone or prednisone). These treatments are usually necessary only for 1 - 3 weeks. About half of these children do not have asthma by the time they reach school age (5 or 6 years old), so pediatricians often do not give them the diagnostic label of asthma.

Some pediatricians wondered if giving these children an ICS every day for a year more would reduce their risk of developing asthma. A theory which is widely believed states that permanent damage occurs (airway remodeling) when asthma is not treated early and religiously. So the NIH funded a large study done at 7 university medical centers in the United States to examine this theory.

285 children ages 2 or 3 were enrolled in the study. All had at least 4 episodes of wheezing during the previous year, and additional risk factors such as eczema (an allergic rash) or a parent with asthma. The children were randomly assigned to take a low daily dose of Flovent (fluticasone) or a placebo inhaler for two years. At the end of the two years of treatment they were followed for an additional year.

The group of toddlers taking Flovent every day didn't grow as quickly as those taking a placebo. On the average, they were about one-half inch shorter, a known ICS side effect. Those taking the drug had fewer wheezing episodes during the first two years, but the same number during the final year when they were no longer taking the fluticasone every day. It's unlikely that pediatricians will be able to convince many parents to give their young child an ICS twice per day, every day, to somewhat reduce the number of wheezing episodes each year but not alter the risk of chronic asthma.

A European study, published in the same issue of the New England Journal of Medicine, found that ICS therapy for infants up to age two also did not prevent progression to asthma. These studies are a blow to companies like GSK and Astra-Zeneca (who were hoping to expand their ICS sales) and to parents eager to reduce the 50% risk that their infant or toddler with wheezing episodes will develop asthma. The majority of these wheezing episodes are caused by respiratory viruses. Only a minority are caused by exposure to allergens, smoke, or air pollution.

Related Topics: New Clue to Development of Asthma, Early Asthma, Later Lung Damage

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Review: Chronic Bronchitis and Emphysema Handbook

If you or a loved one has COPD, read The Chronic Bronchitis and Emphysema Handbook.

The second book that I have read about COPD, written for patients was a pleasure, interrupted only by a walk in the woods with my golden retriever, Mollie Tamalie. This paperback is the second edition of a successful collaboration between Francois Haas, a pulmonary physiologist, and his wife Sheila, a psychologist who is the editor of a complementary medicine newsletter. The book is greatly enhanced by the many unique and original ink illustrations of their colleague Doctor Axen.

The 300 page book, with a retail price of only $16, covers the full spectrum of issues faced by patients with COPD, from expectorant herbs to sexual positions and portable oxygen. The chapters about lung physiology and function are so clear that they should be read by every medical student and respiratory therapist.

I enjoyed the apt analogy that the effect of emphysema on the lungs is "like tearing down the interior walls of a building of multi-room apartments, until each apartment is like one large room." Many readers will identify with and learn from the stories of several patients with COPD.

The authors emphasize the benefits of pulmonary rehab programs and a positive attitude. They include a chapter advice from two top herbalists describing complementary therapies for COPD, including garlic, propolis, kava, and NAC.

I liked the topical political and economic discussions. Since the book was written in 1999, a few sections on therapy need updating, such as the greatly enhanced smoking cessation rates when bupropion or verenicline are used. I was a little surprised with their statements that long-acting bronchodilators are entirely safe and usually effective, which differs from my experience.

Overall, I give this book five stars.

Related Topics: Secondhand Smoke Dwindles, Indoor Air Pollution: Are You at Risk?

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Chantix: New hope for adults with asthma

Chantix: a new pill that could dramatically help half of adults with asthma

Singulair helps about 20% of adults with asthma. Inhaled corticosteroids help about 80% of those with asthma. A few weeks ago (May 2006), the FDA approved varenicline (Chantix from Pfizer), which enables about half of adult smokers to quit smoking.

Half of adults with asthma are smokers and smoking always worsens the airway inflammation of asthma. So I think that Chantix is the best new "asthma drug" to become available in the last ten years. In my opinion, every person with asthma who also smokes should finally decide to quit and then ask their doctor about Chantix.

Some people can quit "cold turkey" but most smokers are physically and psychologically addicted to nicotine. Nicotine replacement therapy (NRT) as gum, patches, or nasal spray can help some people to quit; costs the same as smoking, but doesn't risk heart attacks, strokes, cancer, asthma, or COPD.

Bupropion (Zyban) increases the chance of successful smoking cessation to about 25%. In large head-to-head comparision studies, Chantix roughly doubled the success rate of Zyban.

More than 4500 smokers world-wide have enrolled in clinical studies of Chantix, and 40-50% quit smoking for more than six months. Chantix works by latching onto nicotine receptors in the brain, so its side-effects are much like nicotine itself: about 16% of those taking the low dose feel nauseous and about one-third taking the high dose, but fewer than 5% feel bad enough to stop taking Chantix. About 20% have some insomnia and 10% report vivid dreams. The pills are taken twice-a-day and can be taken safely for 3-6 months.

I have a personal conflict of interest to report with Chantix. I just started consulting with Pfizer on a study of Chantix in 600 smokers with COPD. I am responsible for the spirometry quality assurance program for the study, for which they will pay me hourly for my time up to $50,000 over the three years of the study. This could make me more enthusiastic about Chantix than if I did not have the contract. However, I've been involved in smoking cessation studies in patients with COPD since the Lung Health Study started in 1990, so I do get excited when a better method of helping smokers to quit is found.

Related Topics: One Cigarette May Hook Teens on Smoking, Design Your Personal Quit Plan

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