The inhaled bronchodilator continues to be the mainstay for asthma treatment. This despite the designation of asthma as an inflammatory disease and research findings that support maintenance treatment using corticosteroid medications.
Too often the quick fix of an inhaled bronchodilator wins out over the longer-term advantages of using a steroid. But bronchodilators can provide a false sense of security. Studies show that patients who rely on their bronchodilators are more likely to postpone seeking medical attention until the airways are completely blocked and a medical emergency arises.
In theory, asthma should be well controlled with steroids, as recommended in guidelines issued by the U.S. Department of Health and Human Services for the diagnosis and management of asthma.
Indeed, the death rate associated with asthma has doubled in the last 15 years despite the introduction of relatively safe, inhalable steroids over the same 15 years. Surprisingly, it is not the severe asthmatics who end up having life-threatening attacks. Rather, it is the moderate asthmatic who believes erroneously that if he is not having symptoms, the asthma is under control or gone altogether.
Patients are being told by their physicians to pay more attention to their steroid inhalers. But "steroid phobia" and the lack of any immediate, perceivable results from steroids during an attack -- compared to the perceived effects of an inhaled bronchodilator -- lead many patients to dismiss the therapeutic importance of anti-inflammatory medications. Steroid phobia refers to patients being hesitant to take corticosteroids because they confuse them with androgenic agents and because long-term steroid use has been associated with fluid retention, hypertension, peptic ulcer and osteoporosis.
"Fear of steroids on the part of the patient really depends on whether that patient is a new asthmatic or an old hand at dealing with the disease," says Myrna Daos, pharmacist for MD Pharmacy, which leases space inside the Island Park, N.Y., branch of the Melmarkets supermarket chain. "If the patient has been on steroids for a long time, there is usually no concern. But a new asthmatic may, upon finding out that his prescription is for a steroid, check back with the physician if he has any fears about taking a steroid."
Poor compliance, estimated to be 50%, is the other big issue with corticosteroids. By monitoring and encouraging compliance, pharmacists can greatly help ensure successful treatment outcomes and increase the benefit derived from drug therapy, reducing the mortality of this potentially fatal disease.
Pharmacists need to impress upon patients that, for most people, asthma is incurable. Those afflicted have it for life, just like people with diabetes or hypertension. Asthmatics can even go for a long period -- 10, 20 or even 30 years -- symptom-free. But then, without warning, asthma can recur full-force, particularly if the patient has forgone all medications.
Many pharmacists realize the importance of treating asthma, even when no symptoms are present.
"At our pharmacy, we take the time to explain not only the directions involved in taking the medications, but the importance of controlling asthma in general," says Jeanine Werry, pharmacist at Town & Country Supermarkets, West Allis, Wis.
"We do all we can to educate the patients as thoroughly as possible," whether on corticosteroids or bronchodilators, says Lester Shappell, a pharmacist for Redner's Markets, Reading, Pa. "We counsel the new asthmatic and give him all the brochures, drug reaction printouts and precaution warnings he needs."
Use of inhaled corticosteroids is the preferred therapy for asthma management because they are highly active topically on airway surfaces and weakly active systematically, thereby reducing the risk of pituitary-adrenal involvement. A 1989 study published in the Journal of Allergy and Clinical Immunology showed that, in asthma patients, the ratio of the potency of one inhaled steroid to oral prednisone in reducing airway inflammation and relieving symptoms was 40 to 1.
However, large doses of the inhaled steroids, such as 2,000 micrograms of beclomethasone per day, do inhibit pituitary-adrenal function and cause deleterious effects on the skin, bones and other tissues, the same way systemic steroids can. More common doses, such as 400 micrograms of beclomethasone, have not been shown to cause these side effects.
As for children, strong evidence exists that moderate doses of inhaled corticosteroids are safe, even when given for long periods, causing no decrease in linear growth or skeletal maturation.
New evidence hints at a possible drug interaction between steroids and beta-agonists. Dr. Matthew J. Peters, a research fellow at London's National Heart and Lung Institute, wrote in a July 21, 1993, article in the Journal of the American Medical Association that beta-agonists can cancel the anti-inflammatory effects of the steroid. Steroids work by binding to specific DNA sequences inside cell nuclei. Beta-agonists increase the manufacture of a protein that binds to the steroid-receptor complex that can all but eradicate the anti-inflammatory properties of the steroid.
Additionally, patients whose asthma is worsening tend to use their bronchodilators more frequently, rather than promptly seeking medical attention. A survey conducted at the Bronx Municipal Hospital Center in New York City found that 46% of those asthmatics who had to be hospitalized waited three or more days before getting effective steroid therapy. During that time, patients increased their beta-agonist use ninefold, from four to 38 puffs per day.
Pharmacists must drum into patients' heads that the very hint of exacerbation is a signal to seek medical attention.
It was once thought that children frequently outgrew their asthma. It turns out that many just outgrow their pediatricians.
A Dutch study conducted to determine why asthma deaths keep rising found that breathing difficulties developed in 75% of children with moderate or severe asthma by the time they reached their mid-20s. But by this time, the subjects of the study were seeing another physician who had no idea they were asthmatic. The study also found that 33% of those studied were cigarette smokers -- a brazen habit for people who, in their youth, suffered from the suffocating effects of asthma.
The 1993 meeting of the American Lung Association did little to allay the fears of the steroid-phobic. Arguments ensued over the premise that inhaled steroids are mandatory in controlling asthma because they lessen airway reactivity. Yet no study proves that any connection exists between airway reactivity and patient symptoms.
Similarly, no study has shown that inhaled steroids allow patients with moderate to severe asthma to go into remission. Although many asthmatics improve dramatically after taking steroids, these tend to be patients who exhibit mild, as opposed to moderate or severe, asthma symptoms, says Dr. E. R. McFadden Jr., professor of medicine at Case Western Reserve University School of Medicine, Cleveland.
Patients who believe that because they are mild asthmatics they do not need steroids are wrong, says Dr. Paul O'Byrne, professor of medicine at McMaster University, Hamilton, Ontario. In a study that compared mild asthmatics taking inhaled steroids vs. a placebo, patients on the steroid regimen exhibited virtually no symptoms after eight weeks.
Pharmacists report that prescriptions for inhaled bronchodilators and steroids far outweigh those for systemic forms of these drugs. Care must be taken to instruct patients on the proper use of inhalers.
"We try to impress upon patients that the inhalers are a little trickier to use than they might think," says Daos at MD Pharmacy. "So we take the time to show them how to properly use the inhaler."
Regarding metered dose inhalers, or MDIs, many pharmacists tell patients to determine the amount of drug left inside by seeing if the canister floats in a basin of water. But this "sink or float" test recommended by manufacturers of MDIs does not accurately reveal the amount of actual drug left in the canister. What patients may be measuring is the remaining amount of liquid propellant. Patients who are breathing in the dregs of their MDIs may really be getting inadequate amounts of bronchodilator or steroid.
Physicians, drug companies and the Food and Drug Administration debated the topic of delivery of drug over the life of an MDI in a Nov. 3, 1993, New England Journal of Medicine article.
One doctor complained that by day 17, the strength of the spray declined and asthma symptoms increased. Drug manufacturers stressed the importance of thoroughly cleaning the inhaler every few days. Finally, FDA weighed in that shaking the container, using it at room temperature and not priming it -- and subsequently losing doses -- were critical steps to getting the proper amount of drug.
Dr. Saul Bodenheimer, spokesman for Forest Laboratories, New York, which makes Aerobid, says its MDIs were tested and the conclusion reached was that the last 10 puffs had the same amount of drug as when the canister was full. Other researchers, at the University of Vermont College of Medicine, say patients have no way of knowing whether they are inhaling drug or propellant, and that an exacerbation of a patient's asthma caused by depletion of the drug can be blamed by the attending physician on viral infections or weather changes.
Pharmacists can show patients how to use a calendar to keep track of when the canister should be discarded. If a patient gets a new canister on March 1 and takes two puffs twice a day, he can expect 25 days of medication from a 100-spray canister. However, if he primes the canister once each time, it should only be used for 16 days. After that time, the patient should get a refill, whether or not the canister has liquid left inside.
As to whether a patient should have his mouth open or closed around the dispenser when using an MDI, people disagree.
While some practitioners instruct patients to hold the canister an inch from the lips, a spokesman for Fisons Corp., Rochester, N.Y., maker of Tilade and Intal, points out the flaws in this method. The disadvantage of the open-mouth technique is that the drug can be deposited on the lips, teeth and face, says Dr. Michael J. Tidd of Fisons Corp. in the Jan. 26 issue of JAMA.
The pharmacist can ask the patient if he has been instructed on how to use the MDI. If he has not, the pharmacist should recommend the closed-mouth technique, if anything, to avoid the drug being accidentally sprayed into the eyes.
