Why Use Medications.
In the vast majority people, treatment is quite simple, and treatment includes 2 classes of medications: bronchodilators and corticosteroids. Let’s consider the following vignette to help us better understand how, and why, we use these medications.
Asthma is often worse at night. Parents of children with asthma are all too aware of this annoying truth. As a child, I can recall the innumerable times I was ‘caught’ without an inhaler—typically while staying the night at a friend’s or relative’s house and forgetting to pack a rescue inhaler in the overnight bag. Here an asthma ‘attack’ is triggered by one thing or another, such as sleeping in a dusty or stuffy room, or cat allergy, or a combination of factors. If you can imagine kids rough housing, playing video games sprawled out the floor in the family den, perhaps falling asleep on a dusty sleeping bag—it’s pretty easy to see how these things happen. Not wanting to feel different, or singled out from his or her peers, the first signs of cough or chest tightness are often ignored. Then, it happens that the uncomfortable feelings of not being to able to breathe can longer be ignored. For most children, the experience is accurately described as breathing through a straw—a frustrating, uncomfortable feeling of not being able to push the air out of the lungs. Most children get accustomed to this feeling, and so it’s not usually alarming.
Recently, there was a 9 year old boy in my office in the midst of an asthma exacerbation. His main priority was our office’s salt water fish tank. His brother and him ran from side to side trying to spot the clown fishes, all the while he is coughing, audibly wheezing, and clearly appearing uncomfortable. Thus, it’s often everyone else in the room that is alarmed during these moments. Children with asthma do not panic unless the rescue inhaler is no longer working. And then, I think they are often taken seriously enough—even by well trained physicians. A look of panic in a person with asthma should always prompt action.
So why would a rescue inhaler stop working? The answer to this question is a little complicated, so let’s start with an how these medications work. These are the medications we call bronchodilators, and as mentioned, these are one of two major classes of medications for asthma.
Bronchodilators simply open the small airways, or in scientific terms, dilate the bronchioles. The most commonly used short-acting bronchodilator is a drug named albuterol (hint: it’s easiest to remember this name). Many companies make albuterol, each with a different brand name, such as Accuneb, Proair, Proventil, and Ventolin. Although many people will report that one brand works better than another, they should all be equally effective. The are all considered short-acting since they last approximately 4 hours.
When people have serious episodes of asthma, i.e. the episodes that result in hospitalization and even death, they are often using albuterol repeatedly throughout the day just prior. These are the moments, as mentioned, where the rescue inhalers are simply not working to relieve symptoms. Albuterol remains effective on the muscle within the airways even when used at high doses for days or weeks, and so although we don’t know exactly how or why this occurs, it likely has to do with intense inflammation in the airways. What most people do not realize, is that while rescue inhalers make us feel better and needed for emergencies, they do little to make our asthma better.
This is the part where corticosteroid medications come in, which act to fight airway inflammation. These drugs are inhaled at low doses to coat and decrease inflammation inside the airways. When the intention is to give high doses, typically to fight severe asthma episodes, they are taken as pills, or injected either into the muscle (intramuscular) or vein (intravenous). There have been many corticosteroid drugs developed over the years, and likewise, many more brand names given to these drugs. It’s not important to know all the drug or brand names. To speak the lingo, and better communicate with your care provider, you might simply ask: “Is this medication a steroid?”
Although they are called “steroids,” these differ from the anabolic steroids used by professional (illegally) to pack on muscle. These corticosteroids do not make people stronger. In fact, they often make people fatter and sometimes weaker. They also can cause diabetes, osteoporosis (thinning of the bones), emotional disturbance, trouble sleeping, and lower immunity, among other health problems. In children, the regular use to steroids, even the lower doses given in the inhalers, is known to delay bone growth. In fact, children treated with inhaled steroids end up 1 cm shorter than their peers. The terrible side effects of long-term steroid use is a major driver in the development of the new ‘biologic’ medications developed to treat primarily moderate to severe asthma. Although a person typically needs to take large doses (e.g. prednisone pills) for many days to weeks for a lot of these side effects to occur, such as obesity and diabetes.
Yet, steroids have been the mainstay of asthma treatment for decades. This is because they are effective for most people (but definitely not all), inexpensive, well-studied, and most people that use them do not get the major or long-term side effects mentioned. Although physicians want to minimize your exposure to them, we also want you to live healthy, fulfilling lives. This includes playing sports, exercising, or just enjoying life without fear or need to continually use a rescue inhaler. Thus, we use steroids to reduce the inflammation in the airway, and return it back to normal. The most common way use steroids is to inhale them, limiting the systemic exposure while directing them to the lungs. If things are bad enough, they are taken as pills or injected. Over days of treatment, these medications reduce the inflammation so that the rescue medications are no longer needed—which is this ultimate goal. It’s easy to see the purpose, and the experience of using these medications differs greatly from albuterol, or short-acting bronchodilators. Simply put, steroids treat the airway while the rescue inhalers relieve symptoms at the time.
But wait, there are also combination inhalers that package steroids with bronchodilators. The point is to both relieve symptoms and treat asthma. For this purpose, the drug companies developed medications known as ‘long-acting’ bronchodilators. These drugs work a lot like the short-acting bronchodilator albuterol, but stick around in the airway longer, lasting from 12 to 24 hours. The safety of these long-acting bronchodilators, known specifically as long-acting beta agonists, has been somewhat controversial. It is well known that if these medications are used alone, i.e. without the steroid, it associates with worsening disease and even some deaths. Thus, LABAs are not allowed to be used alone for treatment of asthma.
We also do not entirely know how these medications affect the many different types of cells in the lungs. In particular, our recent evidence suggests that extremely heavy use of these medications, such as one would expect to see in severe patients, it may deactivate or hinder many of our lung’s immune cells. Thus, there is enough concern to warrant efforts that limit our exposure to these long-acting medications. Nonetheless, for most asthma patients these combination medications are proven safe, and can improve their quality of life. For those with persistent asthma, these inhalers provide both on-going treatment (steroids), plus the comfort of keeping the airway open all day, often reducing or stopping altogether need of rescue inhalers. Perhaps the best of both worlds, several drug companies are working to develop combination inhalers that include steroids plus the short-acting inhalers. These combination inhalers offer a combination of treatment and immediate symptomatic relief, and perhaps avoid potential negative effects of the long-acting bronchodilators.