SCIENCE / MEDICINE : Inhaled Steroids Grow in Favor as Asthma Treatment : Medicine: It has become clear that the ailment is a kind of inflammation of the lining of the airways. The drug has been found effective in helping them to heal.
Nearly half of all people who suffer from allergic asthma will be given inhaled steroids these days-- if they go to an asthma specialist for treatment. And, according to the latest research, that is probably the right treatment, particularly if you are over 50.
In the past, it was believed that asthma was primarily a tightening of the muscles that surround the airways between the trachea and the lungs, and a resulting constriction of the breathing passages. Treatment consequently focused on the use of broncho-dilators to open the constricted airways and make asthma sufferers breathe easier. Recently, however, it has become clear that asthma is, most important, a special kind of inflammation of the lining of the airways that leads to contraction of the smooth muscle of the airways.
According to a recent summary of the current treatment of asthma published in the New England Journal of Medicine, an “over-reliance on broncho-dilators” may even be “potentially harmful and may have contributed to the recent upward trend in the rate of death from asthma.” Broncho-dilators, says Dr. Peter Barnes, the summary’s author, “may not influence inflammatory events in the airway, may mask the underlying inflammation by briefly relieving the symptoms, and may allow greater exposure to allergens, irritants and other environmental triggers.”
What should the asthma sufferer do? According to the summary--and to Dr. Philip Norman of the Johns Hopkins asthma and allergy center--the first line of treatment is to suppress the inflammatory response and allow the airways to heal. And the best drugs for this purpose are anti-inflammatories--specifically, inhaled steroids.
According to Barnes, steroids are “grossly under-used,” not only because many doctors don’t prescribe them, but also “partly because patients have a fear of steroids.” Then, too, many patients are unimpressed with steroids because they do not provide immediate relief of asthmatic symptoms. Improvement occurs, but only gradually over a period of time.
The fear of steroids may rest on a valid foundation. Oral steroids, except in very small doses, do produce a wide array of side effects--including osteoporosis, cataracts, weight gain and high blood pressure. However, few side effects have been reported from the use of inhaled steroids, since the doses--administered directly to the inflamed airways--can be kept very low. As Dr. Norman says, “The most important piece of advice I give to patients who have been referred to me is that they should be using inhaled steroids.”
Other anti-inflammatory drugs are the subject of current research, though two of the leading alternatives to inhaled steroids do not look promising (one, ketotifen, has not been proven clearly effective; the other, methotrexate, has serious side effects). Cromolyn sodium, another anti-inflammatory, is most effective as a drug for children and young adults.
Of course, steroids are not the whole story. First, and most important for anyone with allergic asthma, is to avoid allergens. Your doctor can also give you advice about the proper use of broncho-dilators, when appropriate. But it is crucial not to assume that just because asthma is a chronic problem you’ve had for years, there is nothing new in effective treatment.
USING AN INHALER
If you are using a metered dose inhaler--the pressurized portable container that shoots asthma drugs into your mouth and down your throat--it may be that only about 10% of the drug is getting to your airways. The rest may be deposited in your mouth and throat as large droplets that do no good, but give you the full measure of side effects. To get the most from your medication, it must go down into your airways. To permit this: 1) shake the inhaler well to mix the drug and the propellant; 2) tilt your head back slightly and hold the inhaler’s mouthpiece a half inch away from your mouth (see illustration); then, 3) beginning at the end of a normal exhaled breath, inhale slowly over five seconds.
