25Jun
We are commonly asked when a child will “outgrow” their asthma. The Childhood Asthma Management Program (CAMP) is a long-term and large-scale study that assessed asthma and the factors that might predict whether asthma would persist. In the study some children were given an inhaled steroid (budesonide), some were given a non-steroid anti-inflammatory inhaler (nedocromil), and some were given a placebo inhaler. Based on their asthma symptoms during the study, they were divided into three groups: remitting (no asthma symptoms in the past year), persistent (asthma symptoms at least once in each 3 month period), or periodic (not meeting the criteria for either of the other two categories).
Only 6% of children met the criteria for remitting asthma.
All three treatment groups have improvements in measures of their asthma. Surprisingly, the likelihood of remitting (or “outgrowing”) asthma was not influenced by the specific treatment. Observations were made with regard to factors that were associated with a greater likelihood of remitting. These included:
• Absence of allergic sensitization (negative allergy tests)
• Milder asthma
• Older age
• Better lung function
Some of these observations are not a surprise. For example, it seems logical to think one is more likely to outgrow mild asthma than to outgrow severe asthma.
The child who is allergic to furry pets and has furry pets is very unlikely to outgrow asthma.
The child who is not allergic and wheezes only with colds and viruses is more likely to outgrow asthma.
Like so many other aspects of asthma, these observations are just that—observations—and not a crystal ball that will predict with absolute certainty what will happen to a single child with asthma.
It was a bit of a surprise in this study to see that the use of anti-inflammatory medications did not improve the likelihood of curing asthma. Is that a reason to not use preventive medication or any medication at all? Absolutely not! The medications are proven to improve asthma control. That means less interrupted sleep, less missed school and work, less ER visits and hospitalizations, and less use of higher dose oral steroids which carry greater risk with long-term or frequent use.
It is certainly our hope that we will be able to either cure or prevent asthma altogether. But until that day, it is advisable to maintain good asthma control with the tools of trigger avoidance and medications.
01Jun
In 2003, the FDA required the manufacturer of Advair to include a “Black Box Warning” on the package insert of this medication. The reason for this was due to the finding in a large trial that some patients with asthma who were treated with the long-acting bronchodilator, salmeterol, had a higher incidence of asthma related death and other complications from asthma than the group who was not treated with salmeterol. Since 2003 there have been further analyses and studies regarding the use of salmeterol and another long-acting bronchodilator, formoterol. Formoterol is used in the medications Foradil and Symbicort.
Opinions among experts have been polarized. Some well-respected physicians have stopped using these drugs altogether in favor of using higher doses of steroids as well as older medications such as theophylline for treatment of moderate and severe asthma. Others who are equally well respected cite data referring to the overall safety of long-acting bronchodilators salmeterol and formoterol, and continue to use them.
The FDA has recently updated its labeling regarding the use of long-acting bronchodilators. They have concluded that the benefits of these drugs for asthma treatment outweigh the risks, when used appropriately, but that they should be used only in patients whose asthma cannot be controlled with controller medications such as inhaled corticosteroids alone. The new label stipulates that long-acting bronchodilators should only be used along with a concurrent controller medication. In other words, Serevent and Foradil should not be used alone to treat asthma. Once asthma control is achieved, it is recommended to try to reduce medication. If asthma can be controlled with a low or medium dose of inhaled corticosteroids, then long-acting bronchodilators should be avoided.
The safety of long-acting bronchodilators in adolescents has been questioned in the past. The FDA has recommended that products that contain long-acting bronchodilators such as Advair and Symbicort should be used in this age group because the ease of use has helped compliance. This results in improved symptom control and less risk of complications of uncontrolled asthma such as oral steroid use, ER visits and hospitalization.
A recent study published in February of this year in the Journal of Allergy and Clinical Immunology performed an analysis of the use of formoterol (an ingredient in Foradil and Symbicort), in over 23,000 subjects. There was no evidence of an increased risk for serious events, including hospitalization and death in the formoterol group.
We at the Allergy, Asthma & Sinus Care Center review the current safety data of all of the medications that we prescribe. We are often asked if it is necessary to use medications to treat asthma, and if the medications are safe. The “cure” for asthma has yet to be found, and every medication does carry at least some potential for side effects or risk. Overall, we feel that there is a place for medications such as Advair and Symbicort. These medications are a necessary tool in order to achieve control of asthma, but we do always look for opportunities to use less medication when possible.
