Allergies and Asthma

The Best Antihistamines for Sneezing and Nasal Congestion

2008-04-24T18:59:00.008-04:00

About 1 in every 5 people suffer from hay fever, also known as allergic rhinosinusitis by doctors, and I am one of them. Some people suffer all the time (perennial, persistent, constant), usually due to allergies to indoor allergens such as dust mites, molds, animal dander, or cockroaches. Others have allergic symptoms only during certain seasons, because they have become sensitized to grass, tree, or weed pollens. I've had hay fever since preschool days -- a rather typical case.

When we lived in Minnesota, I only had symptoms during the summer, especially when I cut grass or raked leaves, but after moving to southern Arizona, I now have perennial allergic rhinitis (PAR), since weeds release pollen into the air almost any time of the year. After I get a cold or after I am exposed to a high dose of allergens (such as using a line-trimmer to cut weeds), my allergic rhinitis often worsens to include sinusitis.

As a child, my mom gave me Benadryl or Chlor-Trimeton pills. They worked for a few hours to suppress my sneezing, stuffy nose, and itchy eyes, but made me drowsy -- probably a good side-effect from the viewpoint of my mother, considering my hyperactivity. In fact, these first generation antihistamines are also sold OTC (over-the-counter) as sleeping pills. I also got allergy shots and injections of my own urine (from a quack allergist), which "cured me" from complaining anymore about my allergies. I did avoid exposure to grass and weeds (also called secondary prevention) by not playing field sports (baseball, football, soccer) and by refusing to cut the grass.

I can't tell you "what 9 out of 10 doctors recommend for hay fever," but I can tell you what I've done, and tell you what's been published from research studies (controlled clinical trials) of antihistamines. For many years, I got prescriptions for a second-generation, once-a-day, non-sedating antihistamine. They cost about 3 dollars per pill and even with insurance, the co-pay was over $100 per year, so I took them only when I had symptoms. Many others must have done the same, since the U.S. market for prescription antihistamines was then over 4 billion dollars per year.

Everything changed around Christmas, 2002 when the patent for Claritin expired and Wellpoint successfully petitioned the FDA to switch non-sedating antihistamines to OTC. Since then, I've taken generic loratidine every morning; and it only costs $20 a year (for a small bottle of 300 little white pills). Despite the doom and gloom prophecies of allergists and big pharma in 2001, it became a win-win situation. The quality of my life and others improved because we rarely have allergy symptoms anymore, and the profits of the manufacturers of loratidine improved (with 30% market share and 1.4 billion dollars in annual sales).

Allergy sufferers got another Christmas present in 2007 when the patent on Zyrtec, another non-sedating antihistamine, expired. Zertec is now available OTC for about a dollar a pill for the brand name product, while the generic cetirizine costs only $15 to $45 for a bottle of 90 tablets -- enough to get through 3 months of the allergy season for those with seasonal allergic rhinitis. It's also available as a chewable tablet or liquid for children (at a lower dose) and combined with a Decongestant in a capsule.

As an allergy sufferer in the United States, your choices have now been expanded: You can buy generic Claritin OTC, generic Zyrtec OTC, or ask your doctor for a prescription for Clarinex, Allegra, or Xyzal. To determine which is best antihistamine, I read the most recent studies, which are summarized in an excellent review by Doctors Lehman and Blaiss from the University of Tennessee (in the journal Drugs 2006), and a similar review, written for physician assistants, which you can download without cost.

In summary, second-generation antihistamines are the first-line therapy for both seasonal and perennial allergic rhinitis (SAR and PAR). They are very effective, very safe, and last for more than 24 hours. They are much less likely to cause sedation (drowsiness or fatigue) when compared to the old first generation antihistamines. For any of these drugs, the higher the dose, the more likely sedation will be noticed. At the recommended doses for adults, Zyrtec and its twin brother Xyzal are more likely to cause sedation (5-10%) when compared to the others (1-2%).

A small advantage for Zyrtec and Xyzal is that their onset of action may be shorter (about an hour) when compared to the others (1-3 hours). However, a somewhat slower onset of action is not a problem when these drugs are taken every morning (when you brush your teeth) to PREVENT the release of histamine in your nose and eyes later in the day. Antihistamines are much less effective if you wait to take them until you have symptoms.

Allegra (fexofenadine, still by prescription only) is slightly more effective in relieving itchy, watery, red eyes, and less likely to cause sedation at higher (off-label) doses, when compared to Claritin and Clarinex. Blood levels of Allegra are increased by about 40% if you take it with grapefruit juice, erythromycin (an antibiotic), or ketoconazole (an antifungal), but these drug-drug interactions are unlikely to significantly increase the risk of sedation from Allegra.

Bottom line, I will continue to take generic Claritin every morning, because it's effective, doesn't cause sedation at the recommended dose, and cheap. I may try generic Zyrtec when the cost drops towards that of generic Claritin. I will still keep a bottle of generic Benedryl for insect stings and severe allergic reactions, realizing that after taking it I will feel like a space cadet or sleepy. Despite heavy advertising, I personally see no reason to ask my doctor for a prescription for Clarinex, Allergra, or Xyzal, but I am sure that a few patients will feel that these expensive antihistamines are more effective.

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Technorati Tags: hay fever, pollen, allergic rhinitis, sinusitis, Benedryl, Chlor-Trimeton, antihistamines, Claritin, Zyrtec, Clarinex, Allegra, Xyzal, allergies

Are Chantix Side Effects Worth the Risk?

2008-02-04T17:36:00.000-05:00

The risks of continuing to smoke far outweigh the risks of trying to quit. Consider these facts:

One billion people will die from smoking in this century.
Half of persistent cigarette smokers are killed by their habit.
Smoking cessation at age 50 cuts this risk in half.
Smoking cessation before age 30 avoids almost all of the risk.
The success of smoking cessation improves by using nicotine gum; improves more by using Xyban; and improves even more by using Chantix.
About half of those who take Chantix remain non-smokers one year later.

Before Chantix (varenicline) was released by the FDA in the United States (in June 2006), it was clear that it caused minor side effects such as nausea, mood alterations, drowsiness, vivid dreams, or an allergic rash in up to one-third of patients. Many patients have reported these symptoms on Internet message boards. Now, after about 4 million smokers have taken Chantix, about 40 suicides have been reported to the FDA associated with Chantix and about 400 cases of suicidal thinking or behavior. In industry talk, these are called SAEs (serious adverse events), but individuals who experience an SAE (or their loved ones) appropriately use much stronger words.

All drugs have side effects, so doctors and patients considering starting a drug must always weigh the potential benefits against the risk of side-effects. (You can do the math using the above statistics.) Once you notice a side effect (or one is found by your doctor using laboratory tests), the severity of your side effects must be weighed against the benefit obtained by continuing the drug. Sometimes you and your doctor compromise by lowering the dose of the drug or switching to a different drug.

If you are an adult and feel blue (depressed), switching from Chantix to Zyban may be a good idea since Zyban is a low dose of an antidepressant (bupropion). If you get an itchy rash while taking Chantix, stop taking it until you can discuss this with your local pharmacist (free) or physician (good luck). Allergic reactions to drugs can become life-threatening if you ignore them and keep taking the drug.

This week, an FDA spokesperson said that "health care professionals should closely monitor patients for behavior and mood changes if they are are taking this drug." However, in my opinion, it is much more reasonable to advise the patient and their family and friends about this risk. The press and legal community have already done an excellent job of warning people (judging from their websites). It is encouraging that the FDA has responded much more rapidly in releasing the preliminary results of "post-marketing surveillance" for newly released drugs (such as Chantix) since the Vioxx/Celebrex fiasco.

However, their surveillance system is passive, waiting for doctors and patients to report drug side effects. This means that the SAE rates are probably seriously underreported. Perhaps only 1% of SAEs which occur are reported to the FDA after a drug is approved for sale.

Many experts believe that to better protect the public, surveillance should be proactive, with costs and responsibilities to be shared by the FDA and the company which profits from sales of the drug. In my opinion, in the case of Chantix, pro-active surveillance could easily have been paid for by spending a small fraction of the 25% profit from the $681 million in 2007 sales of Chantix.

Smoking cessation is a process for most smokers, who are addicted to nicotine. Before turning to drug therapy, I suggest trying to quit with the help of a support group. Call the smoking cessation helpline in your state or country, such as 1-800-QUITNOW in the United States.

Now for some interesting disclosures. Most of the smoking statistics I listed at the top are from a research paper which you can download for free and read. The renowned first author of this paper, Sir Richard Doll, died at age 92, one year after it was published in the British Medical Journal. After his death, it was disclosed that he had received, but not reported, large consulting fees from chemical companies during his career.

Over the past 3 years, I have been paid a total of about $20,000 by Pfizer for reviewing the quality of spirometry tests done for a study of the effectiveness of Chantix in patients with COPD. My consulting for them on this project continues. Last year, Pfizer also paid me about $4,000 for helping them to produce educational videos to describe how spirometry should be used to evaluate diabetic patients for whom Exubera was being considered. To learn more about the fate of Exubera, click here.

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Technorati Tags: chantix, smoking, quit smoking, FDA, side effects

A New Study of Inhalers to Prevent COPD: Flies in the Ointment

2008-01-17T12:50:00.000-05:00

The treatment of chronic obstructive pulmonary disease (COPD, formerly known as emphysema or chronic bronchitis with airway obstruction) is a rapidly expanding 5 billion dollar per year market for inhaler manufacturers. Large COPD public awareness (promotional) campaigns were started in 2007 by the U.S. National Heart, Lung, and Blood Institute (NHLBI), and the manufacturers of the two inhalers which have been approved by the FDA for COPD: Spiriva (tiotropium) and high dose Advair (a combination of 500 mcg fluticasone and 50mcg salmeterol).

The results of INSPIRE, the second of three very large, international COPD treatment studies were published in the January 2008 issue of the most prestigious pulmonary journal (AJRCCM, aka “the blue journal”). INSPIRE directly compared the effectiveness and safety of these two inhalers in over 1300 patients with severe treated COPD for two years.

Twice as many patients randomly selected to take Spiriva died during the two years of the study when compared to those randomly selected to take Advair. In the patients who also had some type of heart disease or hypertension when they started the study (about half of them), there were 24 deaths in those taking Spiriva, but only 9 deaths in those taking Advair. The higher death rate in those taking Spiriva was apparent just three months into the study. Unfortunately, sudden death from heart disease in individual patients with COPD is rarely even considered as possibly due to a side-effect of their inhalers, because smoking is the most common cause of death from heart disease.

Over 8 million patients with COPD have been prescribed Spiriva since it became available five years ago. Spiriva temporarily relieves shortness of breath in about half of patients with severe COPD, and may slightly reduce the risk of a subsequent exacerbation in those who have previously required hospitalization for a COPD exacerbation. Some adults with asthma are prescribed Spiriva, but the evidence that it helps them is so scanty that the FDA has not approved it for asthma.

More than 15 years ago, I was an investigator of the NHLBI-sponsored Lung Health Study in which 5000 smokers with mild to moderate COPD were randomized to take Atrovent (ipratropium) or a placebo for five years. We reported that study participants taking Atrovent were twice as likely to die, and more likely to be hospitalized with a serious cardiac arrhythmia (heart rhythm disturbance) than those taking the placebo inhaler. Since then, other investigators have also reported that patients with COPD taking Spiriva were more likely to experience a cardiac arrhythmia. Spiriva and Atrovent are both anticholinergic bronchodilator inhalers, but Spiriva is ultra long-acting.

More than one-third of the patients who were enrolled into the INSPIRE study were current cigarette smokers -- the cause of their severe lung disease. The study sponsors apparently did nothing to help them to stop smoking, although smoking cessation is the only treatment proven to halt the rapid progression of COPD. On the other hand, the study investigators did not include a placebo comparison group because "it was deemed unethical to withhold known effective therapies."

I worry that prescribing expensive inhalers for patients with COPD who continue to smoke makes them think that they are “getting the cure” and don’t need to quit. All smokers should be helped with the process of smoking cessation.

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Technorati Tags: COPD, smoking cessation, Advair, Spiriva, health, wellness, heart disease, lung disease

Asthma Inhaler Price Relief

2007-11-13T15:44:00.000-05:00

The Only Cheap ($4/month) Asthma Quick Relievers Left in the United States

I just got back from an asthma conference in Phoenix, with 20 experts from around the United States. Dr. Stuart Stoloff, an active member of the committee which wrote the new EPR-3 asthma clinical practice guidelines, decried the lack of a generic asthma controller medication in the United States.

Sadly, as I've mentioned here before, the FDA and the inhaler manufacturers have worked together during the past couple of years to ensure that new patents for all asthma inhalers which contain an inhaled corticosteroid (ICS) will not expire for another 15 years. The prices of $100 to $300 per month for an ICS will be maintained since no generics will be introduced.

Another speaker, well connected with the FDA and major inhaler manufacturers, showed the expected FDA approval dates for about 8 new ICS or combination ICS plus LABA inhalers during the next 8 years. All of these are "me too" inhalers, with any differences between them and existing ICS or combo inhalers possibly exaggerated in an attempt to gain a slice of the $10 billion per year worldwide market for asthma and COPD inhalers. Of course, all of these new inhalers will be priced about the same as the existing ones ($100 to $300 per month). No truly innovative inhalers are "in the pipeline" (in phase II or III clinical trials). This is a sad situation for under-insured folks in the United States with asthma (or a child with asthma).

Okay, back to the title of this blog. Asthma drugs can generally be categorized into 1) controllers (which you take every day), and 2) quick relievers, which are bronchodilators which are to be used only to temporarily relieve asthma symptoms. Once inhaled, they "kick-in" in less than 5 minutes, and last about an hour or two. These puffers contain beta-2 agonists (aka short-acting bronchodilators); albuterol (called salbutamol outside of the U.S.) is the most popular. It's available as a metered-dose inhaler (MDI, aka an asthma puffer), a solution to be placed in a nebulizer, and a pill. Albuterol MDIs are wildly popular because they are very small, take less than a minute to take a couple of puffs, and are relatively cheap. The albuterol solution is more cumbersome, since it must be placed in a nebulizer and takes 5-10 minutes to inhale the 2-3 milliliters of the liquid. Very few asthma experts ever use albuterol pills, because they are much more likely to cause side-effects (rapid heart rate, nervousness, and tremor), and they take 20-30 minutes to become effective.

Generic albuterol MDIs have been available in the U.S. for several years, and have cost as little as $6 each (less than most insurance copays). Sadly, the FDA has decreed that they be banned, starting in December, 2008. Already, it is rare to find them, as wholesale houses deplete their inventory and don't buy more. The FDA also plans to ban Primatine Mist (quick relief) inhalers, which are currently over the counter (without a prescription) for about $16 each. The new branded HFA MDI inhalers (Ventolin, Proventil, ProAir, and Xopenex) now cost between $30 to $65 each. There is no convincing evidence that any of them are more effective or are less likely to cause side-effects when compared with each other or generic albuterol.

What's left for poor folks? Wal-Mart, Target, and Dey Pharmaceuticals have "come to the rescue," but their solutions (pun intended) are not ideal. Dey makes generic albuterol and generic ipratropium single dose vials with 2.5 mL of liquid to pour into a nebulizer, and Wal-Mart and Target pharmacies sell a "typical" one month supply of these vials (60-75) for only four dollars! Wow, that's about one-tenth the price of the branded albuterol MDIs. What's the catch? Well, you need to have a compressor which plugs into the wall ($20 to $120 each, depending whether you buy it at a local pharmacy or DME store versus Ebay) and some nebulizers ($3 to $30 each, again depending on the source). An alternative is a battery-powered, hand-held ultrasonic nebulizer, which cost from $30 to $150 each, depending on the source. These solutions require larger equipment when compared to an MDI and a handful of vials, and take longer to administer the drug, but silver lining is that the nebulizer+compressor combination is the same as the bronchodilator treatment you will get in most emergency rooms.

So what about the generic ipratropium solution from Dey, which was just added to Wal-Mart's $4/month program? Ipratropium has been around for decades, branded by Boehringer (a German drug company) as Atrovent. Ipratropium has two major disadvantages as an asthma rescue medication when compared to albuterol: 1) it takes 45 minutes to an hour to take effect, and 2) it only works for a relatively small minority of children or young adults with asthma. However, ipratropium brings temporary relief of shortness of breath for about half of patients with COPD due to smoking. For those in whom it is effective, it lasts for 4 to 6 hours. The bronchodilator effect of ipratropium adds to the bronchodilator effect of albuterol, so many years ago, Boehringer introduced a combination MDI inhaler called Combivent. They apparently fell behind in the development of an HFA or DPI inhaler to replace the old CFC Combivent (and thus get another 15 year patent), so they have petitioned the FDA for an delay (beyond 2008) in the ban on CFC Combivent. Meanwhile, the Mothers of Asthmatics have attacked compounding pharmacies for substituting low cost generic combinations of ipratropium and albuterol solutions for the expensive Combivent brand name solution for nebulizers.

If you are concerned that the $4 per month generic short-acting bronchodilators may be less effective than the branded versions, get a peak flow meter (or even better a PiKo-1 pocket spirometer to measure your FEV1) and compare the improvement between the cheap and the expensive solutions (after ten minutes for albuterol and after 45 minutes for ipratropium or the combination. Of course, always, always work with your doctor when contemplating a change in your asthma treatments.

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Technorati Tags: asthma, inhalers, medication, health and wellness

Managing Mild Asthma

2007-09-25T09:17:00.000-04:00

Singulair versus Flovent versus Advair for Mild Persistent Asthma?

There is no question that in general Advair is more effective than Flovent and that Flovent is more effective than Singulair for controlling asthma. Most patients with mild asthma only go to see a doctor during an asthma exacerbation - that's certainly not optimal, but that's human nature. There are so many other responsibilities in life that you tend to ignore problems unless they become severe. The doctor then prescribes what she knows are the most likely drugs to "get you back on your feet" as soon as possible. That usually means a combination asthma controller inhaler (Advair or newcomer Symbicort) and, if your asthma severity is really worrisome, or if you've previously needed hospitalization for an asthma attack, she will prescribe a burst of prednisone.

[Strangely enough, the 10-14 days of prednisone (the strongest medication) will cost less than ten dollars, while each inhaler will cost somebody up to $200. ]

Anyway, within a few weeks, you will be feeling better and back into the yellow zone, and several weeks after that, you will probably be back into the green zone, demonstrating that your asthma is back in good control. What then? What asthma controller medications should you then be "stepped down" to? There are several options.

A new, large study addressed just that question. The investigators randomly assigned 500 children and adults with well-controlled mild asthma to step down to one of three options:

Advair (100mcg fluticasone plus 50mcg salmeterol once each night);
Flovent (100mcg fluticasone twice a day); or
Singulair (a 5 or 10mg monteleukast pill every night; 5mg for kids, 10mg for adults).

About one-third of the patients had experienced an asthma exacerbation during the previous 12 months. About two-thirds of the patients also had allergic rhinitis. This study started in the summer of 2003 at 19 sites in the United States, and was funded by Glaxo (the company that makes Advair and Flovent inhalers) and the American Lung Association (published in NEJM May 2007). A colleague and friend of mine, Dr. Robert Wise at Johns Hopkins, was the principal investigator at the coordinating center. The measures of successful treatment were:

the number of days before another asthma exacerbation
the percentage of days free from asthma symptoms.

So what happened during the 4 months of follow-up for each study participant?

The percentage of asthma-free days was about 80% for all 3 groups, which means that on the average, they didn't need to take albuterol for asthma symptoms for 4 of every 5 days.

About 20% of those who took the low dose Advair once-a-day and 20% of those who took the low dose Flovent every night had an asthma exacerbation, compared to 30% of those who only took a Singulair pill every night. There were 8 different events which were considered an asthma exacerbation (aka an event), including urgent care visits for asthma, the need for a burst of prednisone, the need for an excessive amount of albuterol for two or more days in a row, or a worrisome fall in lung function (FEV1 or peak flow). Half of the exacerbations were because the FEV1 had decreased more than 20% from the beginning of the study (even though the patient may have felt fine).

Side-effect rates (aka adverse events) were similar in the 3 groups, except that those taking Singulair reported fewer upper respiratory infections (27% versus 38%), fewer lower respiratory infections (7% versus 14%), and fewer episodes of fever (15% versus 25%). Hmmm, it sounds like even a low daily dose of fluticasone substantially increased the risk of viral respiratory infections, but reduced the risk of an asthma exacerbation. Since respiratory viruses are the most common cause of asthma exacerbations, this is a paradox.

I agree with the authors' conclusion that "individual patients and their physicians must choose a treatment regimen for asthma that balances efficacy with actual or perceived risks and maximizes adherence. No single approach will provide the best combination of these factors for all patients with asthma."

Don't let your doctor practice "cookbook medicine" (one size fits all) for your asthma therapy. Once your asthma is well-controlled, ask her about stepping down your therapy. Learn all that you can about your asthma and asthma medicines. WebMD provides many resources for those with asthma.

The High Cost of Asthma Medications in the United States

2007-08-24T14:35:00.000-04:00

In my personal opinion, the high cost of asthma therapy in the United States (over $100 per month for each controller inhaler) is due to the greed of the big drug companies, and the costs will only get higher during the next two years. Inhalers are a ten billion dollar a year market worldwide, and growing rapidly. The profit is very, very high, even considering the inflated R&D expenses. During the past 7 years, pharmaceutical companies have successfully lobbied the FDA and Congress to ban any generic asthma inhalers (controller or reliever).

The problem with health plans fully covering every asthma inhaler is that it would provide no incentive for the manufacturers and distributors to control (lower) prices. The inhaler manufacturers run almost all of the research on asthma inhalers, so the new ones are only compared to placebo inhalers, and no head-to-head comparisons are done (for efficacy or for side-effect rates). It's amazing that the FDA allows such placebo-controlled studies of me-too drugs (or reformulations with new inhaler devices).

It is highly likely that all of the ICS medications (generics included) - after controlling for the dose delivered to the lungs - have roughly the same efficacy and side-effects for more than 80% of those with asthma. However, it seems as though nobody cares enough about consumers and poor folks to conduct such a study to disprove such a hypothesis.

The only non-industry people in the United States who could run such a study are

the Lung Division of the NIH-NHLBI and
the American Lung Association's Asthma Clinical Research Network (ALA-ACRC).

However, the majority of the staff and investigators of these programs have been "feeding at the trough," so I don't think you will see such studies funded by them anytime soon - unless a new asthma/COPD patient advocacy group starts talking to the press.

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Technorati Tags: medication cost, health care, asthma, inhalers

Asthma and Acid Reflux

2007-07-06T17:17:00.000-04:00

Once a year, the largest pulmonary meeting in the world is held by the American Thoracic Society (ATS). This year, it was in San Francisco, with over 16,000 attendees. One of the major topics is asthma. I reviewed all of the asthma abstracts (short summaries of research done during the previous year), so during the next couple of months, I will blog about some of the highlights from the ATS meeting.

40% of patients with cough variant asthma (CVA) have acid reflux (GERD). Both of these disorders are common, but how common depends on exactly how one defines mild disease and how many medical tests are done to confirm an abnormality and rule out other possible causes for the symptoms of cough and heartburn.

For decades, people who over-indulged with food got heartburn and just treated it with cheap antacids, like TUMS. Then expensive, and somewhat more powerful acid-blocker pills became available. An a couple of years ago, an even more expensive proton pump inhibitor (PPI) that blocks all stomach acid production went off-patent and over-the-counter.

Now patients with heartburn symptoms are sought by multi-million dollar ad campaigns, which suggest that only an expensive PPI should be used for GERD.

Over half of people with asthma are over-weight. Obesity makes acid reflux much more likely. Both asthma and GERD can cause a chronic cough; therefore, asthma and GERD often co-exist. GERD can sometimes (but certainly not more than half of the time) worsen asthma.

So should everyone with asthma and a chronic cough take a PPI every day? Should everyone with a chronic cough get a 500 dollar, 24 hour pH test for acid reflux?

I think that a more reasonable approach is to try a PPI for several weeks to see if it makes a substantial reduction in coughing and generally improves asthma control. For an objective comparison, you should maintain a daily asthma symptom diary for two weeks before you start the PPI and for two weeks while using the PPI.

Please help others by posting your experience on our WebMD asthma message board.

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Why One COPD Medication Instead of Another?

2007-06-13T17:10:00.000-04:00

Why Take a Bronchodilator? Bronchodilator inhalers and pills relax the airways, making them wider so that you can breathe more easily. The goal of bronchodilator therapy is to reduce shortness of breath. If you are not short of breath, or if they don't noticeably relieve your shortness of breath, then perhaps you don't need to take a bronchodilator regularly. Discuss this with your doctor.

What Side-Effects are Possible from Bronchodilators? Bronchodilator inhalers and pills are stimulants, like the caffeine in coffee and tea. Thus you may experience nervousness (anxiety), shakiness (tremor), a more rapid pulse, insomnia, or stomach upset (nausea). These will only last for the duration of the effect of the bronchodilator (2 to 4 hours for short-acting inhalers, but 12-24 hours for long-acting inhalers). If you also have heart disease, you may experience palpitations (worrisome cardiac arrhythmias), or angina. If this happens, contact your doctor and discuss it.

Why Take an Inhaled Corticosteroid? These inhalers are designed to reduce airway inflammation and swelling. This beneficial effect takes several days of daily use. These inhalers are often used when some degree of asthma is also present along with COPD. When taken every day, these inhalers may reduce the risk of an exacerbation (temporary worsening) of COPD.

What Side-Effects are Possible from Inhaled Corticosteroids? Many people develop yeast (Candida) infections in their throat (thrush) after using them for several weeks or more. These yeast infections are not serious, but often cause a sore throat, a sore tongue, a white coating at the back of the throat and tongue (which you can see by shining a light at the back of your throat and looking in a mirror). These yeast infections sometimes extend to your vocal cords, causing a change in your voice (hoarseness). Use of a spacer and gargling after taking the inhaler can reduce the risk of thrush. Antifungal lozenges (Nystatin, TM) can be prescribed to kill the Candida yeast.

High daily doses of inhaled corticosteroids (1000 mcg or more) taken for long periods of time may also cause some of the side-effects of prednisone (see that box). Poverty is also a possible side-effect, if you have to pay for these brand-name inhalers out of your own pocketbook.

Why Take Prednisone? Prednisone pills are strong medicine, but very inexpensive since they are generic. They reduce the airway inflammation caused by viral respiratory infections. Prednisone (or its expensive cousin, prednisolone) is often given to treat a COPD exacerbation (worsening).

What are the Side-Effects of Prednisone? Because it is so strong, and distributed to the entire body, prednisone causes some side-effects in most patients. The higher the dose, the more likely side-effects will occur, so most doctors like to stay below 60 mg per day. The longer the time that prednisone is taken, the more likely that serious side-effects will occur, so most doctors like to give only "bursts" of prednisone for 5 to 14 days.

When taken for only a few days, prednisone may cause changes in mood (good or bad) or increased appetite. When taken for months to years, prednisone may cause serious side-effects, such as adrenal suppression (so you must not stop it cold turkey), fluid retention (a moon-shaped face), thinning of the bones (osteoporosis), cataracts, immune system suppression (increased risk of infection), and many other possible side-effects.

Why One Inhaler Versus Another? The primary goal of inhalers is to deliver most of the medication deep into the lungs, where it will be most effective. A secondary goal of inhaler devices is to minimize the amount of drug deposited at the back of the throat.

Small inhalers which you can put in your pocket or purse are generally preferred by patients. These are called metered-dose inhalers (MDIs). Over the last decade, they have evolved to become easier to use, more efficient, and more expensive. In 2007, the FDA eliminated generic albuterol, which used freon as a propellant, so it has been replaced by HFA propellants or by dry powder inhalers (DPIs). The best new inhalers are breath-activated, triggering themselves automatically when you begin to inhale deeply. This makes it more likely that most of the medication will be delivered deep into your lungs. Dry powders and spacers reduce the amount sticking to the back of your throat.

Why Use a Nebulizer Instead of a Pocket Inhaler? The primary advantage of a nebulizer is that you only breathe quietly. Some doctors also believe that nebulizers are more effective for some patients. Nebulizers to deliver a mist of medication have been around for more than 100 years. The air pressure needed to nebulize the liquid medication was first generated by a hand-bulb, then a tank of oxygen, then an electric pump (compressor), and most recently by ultrasound. Usually, about 3cc (about a teaspoon) of the medication solution is placed into the nebulizer. Then you breathe quietly from the nebulizer mouthpiece for a few minutes.

The Disadvantages of Nebulizers:

you have to pour the medication into the nebulizer;
it takes longer to deliver the medication;
the device is more expensive;
compressors are noisy and must be plugged into the wall;
the nebulizers should be cleaned routinely.

On the other hand, the primary disadvantage of most pocket inhalers is that technique is important -- you have to figure out how to trigger the inhaler at the beginning of a slow and very deep inhalation and then hold your breath for several seconds. Sometimes you are not confident that the pocket inhaler actually delivered the medication into your lungs, because you can't see the mist or powder.

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Technorati Tags: COPD, chronic obstructive pulmonary disease, bronchodilator, corticosteroid, prednisone, inhaler, nebulizer, health and wellness

Latent Tuberculosis: Dad's Diagnosis

2007-06-07T10:53:00.000-04:00

Editor's Note: WebMD Staffer Leona Perry has been taking the story of tuberculosis patient Andrew Speaker a little more personally than the rest of us here at WebMD. Her sister Renee was diagnosed with tuberculosis in late 2004 and it put their family into a difficult medical situation. Leona told her story and Renee shared her tale; Here's what happened to their dad.

When we all found out my sister Renee had TB, my parents immediately made an appointment with their local health department to be tested.

After a couple of days, Mom's test site looked normal. But Dad's was red and raised. He had to go in for a chest x-ray and more testing.

The x-ray revealed a dark, scary spot on his lung, but sputum tests came back negative for active TB. The doctors diagnosed him with Latent TB, and told him that the spot was probably a sign that sometime earlier in his life he had the active form of the disease and just didn't know it.

He told us he suspected that he may have contracted it as a child from others in his family that may not have known they had TB.

My dad's grandmother died of tuberculosis, back when it was called consumption. He remembers his dad, my Papaw Leo, telling him how his mother had been in a Sanatorium for a long time when he was a child. She apparently passed away there.

My great Aunt Naomi, Papaw's sister, was just a kid herself but had to take over all of her mother's duties around the house, including caring for her siblings and her dad.

Because my dad's TB was the latent form, the doctors said Renee couldn't have gotten the disease from him. She will probably never know exactly where she came in contact with it.

They say that everything happens for a reason. I wouldn't wish TB on my sister or anyone else, but what if my dad's Latent TB had become active when he was older and couldn't fight off the disease or handle the long course of treatment? He already has Type 2 Diabetes. It's probably a blessing that he was tested and found out when he did.

Dad was put on antibiotics for six months to kill the TB bacteria. He is now TB free.

I have to say that I'm glad medicine has advanced to the point that tuberculosis isn't the killer it once was. If you catch the disease early and get the right treatment you can beat it and even keep any complications at bay.

Our family was blessed. I wish the best to any family this disease touches.

Previous: Tuberculosis and My Sister: Leona's Story, Tuberculosis: The Cough That Never Ends, Tuberculosis Diagnosed: Start Spreading the News, Tuberculosis Treatment: The Road to Recovery

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Tuberculosis Treatment: The Road to Recovery

2007-06-03T12:32:00.000-04:00

Editor's Note: WebMD Staffer Leona Perry has been taking the story of tuberculosis patient Andrew Speaker a little more personally than the rest of us here at WebMD. Her sister Renee was diagnosed with tuberculosis in late 2004 and it put their family into a difficult medical situation. Leona told her story; now it's Renee's turn.

I felt run down all the time, and like I said before, my cough was really bad at night, so I wasn't sleeping very well. Brad had given up sleeping with me because he couldn't get any sleep either. I lost a lot of weight, too. I went from 125 lbs down to around 115. That part I really didn't mind too much.

The nurses at the Health Dept were great and made it as pleasant an experience as they could. Mary, my main nurse, answered every question we had.

Brad took me out to the park on the weekends to walk around, since I couldn't go shopping. I could tell that my lungs were being affected because I couldn't walk a half mile before I was completely out of breath and panting.

After 3 weeks of treatment I was declared to be safe in society again and was able to go back to work. I was very lucky that the company I work for had a sick day policy of 30 days at that time, or I would have had to go on short-term disability.

I then had to go back twice a week to give samples, and I was also taking several types of antibiotics that I was only allowed to take with the nurses at the Health Dept watching me. They evidently have a lot of people who actually refuse to take the medicine, so it is not a take-home option.

When I asked how I could have gotten the disease, I was told that the foreigners coming into our country are bringing this disease in from the Third World countries. Many of them are not getting treatment, so it's becoming more prevalent again.

I finally finished all of my medication at the end of August 2005, and then I was sent for another set of x-rays to make sure the disease was no longer in my lungs.

The sad part is that I did actually infect one of my friends/coworkers, Kenny. He did not have the active type so he was put on the preventative medication for nine months. This is an elective medication, but if you don't take it, the disease could become active.

FYI...if you see someone walking through the mall with a mask on, leave immediately. They could be one of those people who is supposed to be quarantined at home and thinks as long as they have their mask on they are not harming anyone else.

Previous: Tuberculosis: The Cough That Never Ends, Tuberculosis Diagnosed: Start Spreading the News

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Tuberculosis Confirmed: Start Spreading the News

2007-06-02T14:56:00.000-04:00

Technorati Tags: tuberculosis, TB, Andrew Speaker, public health

Tuberculosis: The Cough That Never Ends

2007-06-01T18:27:00.000-04:00

Photo by Leona Perry

Editor's Note: WebMD Staffer Leona Perry has been taking the story of tuberculosis patient Andrew Speaker a little more personally than the rest of us here at WebMD. Her sister Renee was diagnosed with tuberculosis in late 2004 and it put their family into a difficult medical situation. Leona told her story; now it's Renee's turn.

I had this cough that started around Halloween of 2004. It started out like a little tickle in my throat, and I would cough rarely. Then, I started to cough on a regular basis, and I assumed I had some type of a cold.

I went to the doctor and was told they could hear wheezing in my lungs, and they thought it could be something bronchial. I was given some medicine and took that for a week. The cough seemed to go away.

About a week later, the cough started up again and it was really bad at night. I went back to the doctor, and they ran all kinds of tests. I was a little anemic, but, other than that, they couldn't find anything wrong with me. The doctor thought maybe it was a type of allergy, and put me on Claritin. She also gave me a cough medicine with a narcotic in it to take at night to help me sleep. Because of the excessive coughing, neither I, nor my boyfriend Brad were getting any sleep.

By the time the doctor actually tested me for tuberculosis, it was the middle of February 2005. When the doctor told me they were going to do the TB skin test, she acted like she was pretty certain it would come back negative, but it was kind of a last ditch effort to find out where this cough was coming from.

They did the skin test, and I went home.

When the skin test started welting up the very next day, my boss and I were looking the disease up on the Internet. The first thing that's mentioned is death, so yeah, I was scared. Then we did some more research and realized that it was contagious but treatable.

You go back after the second day to have the skin checked, and when I went back, there really was no mistaking that I was positive for TB. The skin had welted up about a quarter of an inch off my arm in a quarter-sized circle. I was immediately masked and sent to the TB clinic at the Durham County Health Dept. I was quarantined for three weeks.

I was only allowed to be outside. I was told that the disease would dissipate in the air, but if I went into buildings there was nowhere for the disease to travel, so I had to wear a mask when I went to the Health Dept.

Coming Next: Diagnosis: Start Spreading the News

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Tuberculosis and My Sister: Leona's Story

2007-06-01T12:37:00.000-04:00

Editors' Note: WebMD Staffer Leona Perry has been taking the story of tuberculosis patient Andrew Speaker a little more personally than the rest of us here at WebMD. Her sister unexpectedly was diagnosed with tuberculosis in late 2004 and it put their family into a difficult medical situation. Here's her story:

My husband and I always take our kids to visit our families in South Carolina every Christmas.

In December 2004, we all ended up at my mom's on Christmas afternoon. My sister, Bonnie, drove down from Charlotte, N.C., and my sister Renee, and her boyfriend, Brad, had just come in from Durham.

Renee was coughing. "I've got this cold I just can't seem to kick," she said. I'd had pneumonia before, so I suggested she might get that checked out. She sounded pretty bad.

A couple of weeks later my mom called. "Leona, I have some bad news..." I hate it when my mom starts a conversation with those words. I'm always geared up to find out who has passed away. But, what she told me next was almost worse. Renee had gone back to the doctor and had some tests run. She had TB (tuberculosis).

I didn't know much about TB, but I did know that it could be deadly. Way back in the day, they called it "Consumption" and a lot of people didn't live through it. I had a mild panic attack about my sister BEFORE my mom handed out even more bad news...Renee had been highly contagious when she was coughing all over us at Christmas. (Sorry, Renee!)

Everyone in the family who had had any contact with my sister during the past month was going to have to be tested for TB. I had to call my local health department and let them know my kids had been exposed. They told us to contact our pediatrician immediately to set up appointments to have the tests done.

I sat the kids down and explained what was happening. They were worried about their aunt, but they also wanted to know what type of test they were going to have to take. I told them it would be a Tuberculin Skin Test, and went immediately to my handy-dandy WebMD to find a good explanation of what it was going to entail. My son, who was seven years old at the time, still didn't like the idea that they were going to stick a needle under his skin and put something in there.

As a mom, I wasn't half as worried about the little bit of pain my kids were going to have to endure for the test as I was that they might actually have TB. All sorts of nightmares were running through my mind: "Colton is so little. Can his body take this disease?" "What if one of the girls has it? Will they be able to kick it?" "Even if they kick it, what kind of permanent damage would it do?" Scary, scary thoughts.

I also had to call all the parents of my kids' friends. If my kids came up positive on the test, they'd then have to have their kids tested. See how this begins to snowball?

We were all on pins and needles the next few days while we waited to see if the tell-tale bumps would appear inside the circles the nurse in our pedi's office had drawn around the exposed area.

No bumps. Yay!

But, we still had to go have the pediatrician confirm that there REALLY were no bumps so she could alert the Health Department that we were all clear.

Finally, the fear was over on our end. But Renee's journey was just beginning.

Renee's story begins with a nagging cough. Read about her scary story here.

We'd love to hear what you think. Add your comments below..

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Allergies? Don't Blame the Fragrant Flowers

2007-04-24T10:00:00.000-04:00

Close to Spectacular

It's Springtime in the northern hemisphere, so many of us are sneezing again. Although the daffodils are blooming in Minnesota and the cherry blossom festival is underway in Washington DC, these beautiful flowers are not the cause of your hay fever acting up again. Plants and trees with flowers don't generate much airbourne pollen.

It's the trees, grasses, and weeds without flowers which are tickling your nose, or congesting your sinuses. They are spreading billions of very small pollen granules into the wind. The trees and plants with flowers, on the other hand, are attracting insects as their method of cross-pollenation. Some people have associated flowers with allergic rhinitis, but their reactions were more likely due to the molds growing in the flower pots, in the water, or on the dead leaves.

Springtime is indeed a time for allergic misery for many people, but instead of refusing flowers from your lover, get out the antihistamines, sinus rinse, and nose sprays. Use them before you are likely to be exposed, because they are much better at preventing inflammation in your nose than treating it after the allergens have already done the damage.

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TORCH: Towards a Revolution in COPD Health? Not really.

2007-03-20T13:15:00.000-04:00

Last month, the long-awaited results of the TORCH study of Advair (aka Seretide outside the U.S.)(TM) for patients with moderate to severe COPD were published, but were no doubt disappointing to patients with COPD and investors who own GSK stock. Optimists spun the results as "positive" with a 17% relative reduction in death rates for those taking the combination inhaler for 3 years when compared to those taking the placebo inhaler. However, the absolute difference in deaths during the 3 years from any and all causes was only 2.6% (12.6% vs 15.2%) and this small difference was not statistically significant.

An Advair Diskus 500/50mcg (the high dose used by the TORCH study) costs about $270 per month. The drug was associated with a lower hospitalization rate for COPD exacerbations, but 32 patients (or their insurers) would each have to pay about $3200 per year (over $100,000 total) to prevent just one of these hospitalizations.

But doesn't taking the combo inhaler make the patients feel better? Well, after taking Advair for one year, about half of them did generally feel noticably better than those taking the placebo inhaler, according to scores on a standardized COPD questionnaire (St. Georges). However, over the next two years, the disease progressed in all patients as their lung function fell further and they became more short of breath. Those taking the inhaled corticosteroid (fluticasone), either alone or in the combo inhaler, were also significantly more likely to get pneumonia (a serious side-effect). I'm personally not as optimistic (or biased) as my colleagues who were paid to participate in the study, one of whom said, "We clearly showed that the combined treatment helps prevent disease-related exacerbations and helps people feel better. But does it help them live longer? We can't say for sure; but we think it does."

About half of the patients had been taking a COPD inhaler before they entered the study, so it's not surprising that over six billion dollars was spent on Advair inhalers last year (for asthma or COPD), plus billions for Spiriva or Atrovent COPD inhalers.

I worry that patients believe that these inhalers are "curing" their lung disease and that they don't have to take the effort to stop smoking. Forty percent of the 6000 COPD patients in the TORCH study were still smoking, despite their advanced lung disease due to their habit. Sadly, I think that doctors are taking the easy ten second "solution" of writing a prescription for an expensive inhaler instead of the time-consuming counseling over several visits needed to help a nicotine addict to quit. Smoking cessation is the only intervention proven to slow the progression of COPD. It has been proven several times that inhalers are not the cure for COPD.

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Updated Asthma Guidelines

2007-03-06T13:45:00.000-05:00

Every five years, guidelines for physicians who diagnose and treat asthma are updated by the NAEPP's Expert Panel to incorporate newly published evidence from research studies. Last weekend in San Diego I attended the largest allergy meeting in the world, the annual congress of the AAAAI, where the 2007 update of the asthma guidelines was presented by some of the panel members. The full 600-page document is available for downloading and public comments before March 15. One of the panel members, only half-joking, said that the only people who have commented on previous drafts are employees of asthma drug companies who believe that their drug should have received more emphasis. About 20 of the 4000 allergists at the meeting stood at the microphones to ask questions of the panel members during the final 30 minutes of the session.

Here are some key differences between the 2007 guidelines and previous editions.

Current asthma treatments do not prevent disease progression.
Even patients with intermittent asthma can have severe asthma attacks (exacerbations). S
Single steps taken to reduce indoor allergen levels (such as just buying an air cleaner or just using allergen-proof bedding) are generally ineffective.
Formaldehyde and VOCs (chemicals that smell funny) can worsen asthma.
Every patient with asthma should have a written asthma action plan which includes both daily management and early recognition of asthma exacerbations.
When a patient is regularly taking an ICS, but still has inadequate asthma control (remains in the yellow zone), the addition of a LABA (like salmeterol or formoterol) may be a better option than doubling the daily ICS dose.

Recommended emergency room management of asthma attacks was updated.

Levalbuterol (Xopenex) may be used instead of traditional racemic (inexpensive) albuterol.
For severe attacks not responding to traditional therapy, magnesium sulfate or heliox therapy should be considered.
Ipratropium (Atrovent) is no longer recommended for hospital inpatient asthma therapy.
A primary goal of ER therapy (before the patient is sent home with an ICS and other therapy) is an FEV1 of more than 70% of the predicted (normal) value.

Sadly, it may take years before the doctors who treat you for asthma incorporate these new guidelines into their routine practice. For example, large studies have shown that fewer than half of patients were taking an ICS (the best asthma controller therapy) during the three months after an asthma attack.

Related Topics:

WebMD Video: Asthma Medication Tips

WebMD Video: Asthma and Ozone

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Ten Tips for Winter Sports with Asthma

2006-11-03T12:23:00.000-05:00

Cold air is dry air. Exercising in dry air causes bronchospasm (EIB). Everyone with asthma gets EIB if they exercise strenuously in cold weather. However, if your asthma is well-controlled and you prepare for the trip, skiing or snow-boarding is lots of fun. Here are some tips if you are planning to participate in winter sports:

Be sure to get a flu shot (since airplane travel increases your risk of getting the flu).

Ask for a prescription of two weeks of Tamiflu, which can prevent influenza and reduce its severity and duration if you get the flu. Fill the prescription and take the pills with you. (Details here)

Get a written asthma action plan from your doctor. Consider also taking your peak flow meter or PiKo1 to monitor your lung function.

Ask your doctor for a prescription for 7 days of prednisone (perhaps fifteen 20mg pills) to take with you in case you fall into the red zone. Finding a doctor quickly and inexpensively at a ski resort is not easy.

If you walk into a hotel room and it smells musty or smoky, ask for a different room. Take an allergen cover for your pillow.

If you will be exercising in the snow (like skiing or snowboarding), take a mask which will conserve the moisture that you exhale. At least wrap a scarf over your nose and mouth whenever possible. Premedicate to prevent EIB.

Be sure to faithfully take your asthma controller medications during the week prior to the trip and throughout the trip. Take an extra albuterol MDI.

Avoid folks with colds and coughs.

Don't use the fireplace in the condo. Run the exhaust fan when showering or cooking.

Eat well (good nutrition) and drink plenty of water (to avoid dehydration).

Have fun!

Related Topics: The Asthma-Ozone Link, Treating Asthma: Personalized Medicine

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Antihistamines aren't Addictive!

2006-10-10T06:11:00.000-04:00

Your body doesn't become addicted to antihistamines anymore than your car becomes addicted to having a windshield. Okay, let me explain this odd analogy: If you have nasal allergies, and you inhale some of the allergens to which you've become sensitized, white cells burst open, releasing histamine, which quickly begins inflammation in your nose and you get symptoms. If there was some antihistamine in your body at the time, this inflammation is blocked. Sort of like the windshield of your car keeping dust and bugs from hitting your face when you drive.

If you remove the windshield of your car, bugs will again hit your face. If you then replace the windshield, it won't remove the bugs already in your eye. Does this mean that you or your car are "addicted" to the windshield?

In medical terms, your body does not develop tolerance to antihistamines. Once you take them for months to years, you don't need increasing doses just to get the same protection that you got originally. If you stop them "cold turkey" you are no more sensitive to allergens than when you began taking the antihistamine in the first place.

When only first generation antihistamines were available, they put me to sleep, so I only took them when my nose was stuffed up and my eyes itchy and red. They weren't very effective then, but I didn't complain because I was asleep.

When second generation non-sedating antihistamines came along, I took them an hour or two before planned walks into areas with grass or weeds. They worked great and I didn't get symptoms when I took them before allergen exposures. However, I didn't take them every morning because they cost a dollar per pill and I am frugal.

Now that generic Claritin only costs 3 cents a pill, I take it every morning. If I know that I will be working outdoors pulling weeds or using the weed whacker, I take two in the morning and wait a couple of hours before starting the yardwork. It works great.

Zyrtec is generally stronger than Claritin, but it's also ten times as expensive and requires a prescription. All antihistamines are much, much more effective when taken hours BEFORE allergen exposures instead of only after you get symptoms. That's the main reason that many people suffer needlessly. As with asthma, think PREVENTION.

Related Topics: Taking the Itch out of Fall Allergies, Conquer Allergies!

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Smokers with asthma: Just Quit!

2006-06-30T12:49:00.000-04:00

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

2006-06-22T18:25:00.000-04:00

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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