Asthma, Allergy & Immunology 05

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Among the newer treatment options for patients with severe asthma is

combination therapy including an inhaled steroid and a long acting

b2-agonist. Macrolide antibiotics are receiving renewed interest

because Chlamydia and Mycoplasma are appearing in lung biopsies of

severe asthmatics.

Asthma, Allergy & Immunology

Asthma needs to be treated with anti-inflammatories

Inhaled steroids reduce inflammation and decrease morbidity and

mortality.

by Jill Chamberlain

Correspondent

January 2005

Although pediatricians seem to be doing a good job of prescribing

asthma drugs that relieve airway hyperresponsiveness, such as

albuterol, they are coming up short as far as treatment of the

underlying inflammation.

Inhaled steroids are the only medications that have been shown to

reduce inflammation, illness and deaths in patients with persistent

asthma.

Credit: © J. Reid/Custom Medical Stock Photo

Asthma continues to occupy the top position among common chronic

disorders in children and adolescents, with some 5 million U.S.

children affected as of 2001. About three-fourths of these children

have persistent asthma.

" We are ignoring the fact that the key to asthma is chronic

inflammation in the lung, and it really should be treated with anti-

inflammatory drugs, " said Theresa Guilbert, MD, assistant professor

of pediatrics at the Arizona Respiratory Center, University of

Arizona, at the AAP 2004 National Conference and Exhibition in San

Francisco.

Inhaled steroids are the only medications that have been shown to

reduce inflammation, illness and deaths in patients with persistent

asthma. Even in children, the benefits of low- to medium-dose

inhaled steroids outweigh the risks.

Of those patients with severe-persistent asthma, the most serious

form, only about 20% are taking inhaled corticosteroids, which the

AAP, the American Academy of Family Physicians and the NIH concur

should be the preferred drug for anyone with that type of asthma. In

the pediatric arena, the lack of prescription of inhaled steroids

might be ascribed to the perception that most children have mild

disease and are not at risk for adverse outcomes. But that is not

the case, said Guilbert, citing an Australian study of 51 children

who died from asthma between 1986 and 1989, which found that equal

percentages would have been classified as having mild-persistent

asthma, moderate-persistent asthma or severe-persistent asthma at

the time of death. There has been concern that steroids may affect

growth in children, but a number of studies have now dispelled that

association, provided the steroids are used rationally in low or

medium doses.

Aggressive treatment needed

Data now affirm that the earlier asthma is diagnosed and treated,

the better the children do later in life. The Children's Respiratory

Study, an important investigation that assessed more than 1,000

newborns enrolled at birth and followed over time, identified an

asthma predictive index, which seems to correlate with children who

wheeze during their school years and may prove to be a useful tool

in the clinic. Another consideration is whether a child already has

persistent asthma at a young age. " Even if they are only 2 or 3

years of age, if they have persistent asthma, they should be treated

the same way they would be if they were older, " Guilbert

emphasized. " If they are using an albuterol inhaler more than twice

weekly, or waking up due to asthma symptoms more than twice per

month, they may have persistent asthma and need a controller

medication. "

It is important to stabilize patients and keep them on the first

round of anti-asthma medications chosen for two to three months,

according to Guilbert. If they are doing well, stepping down therapy

is an option. For those patients who have environmental changes, a

step up in therapy might be mandated.

When the therapeutic program is effective, children with asthma

should be nearly symptom free, with few absences from school. They

should be running and playing, not sitting quietly on the couch to

avoid activity.

Usually young children are brought to the office because of

exacerbations, whereas older children see the doctor because of

symptoms that occur when they participate in sports. For these

patients, spirometry is an important diagnostic tool to assess

pulmonary function. Of particular concern are patients with low peak

flow in the morning, which signals low pulmonary function at night —

a feature commonly linked with death.

Even specialists do not routinely measure airway

hyperresponsiveness, but certain features of the disease can serve

as clues about airway status. For example, nighttime problems or

exercise-induced asthma suggests twitchy airways. Inflammation

similarly is not routinely measured; knowing the levels of

peripheral eosinophils and immunoglobulin E (IgE) is useful. The

presence of atopic dermatitis and parental history of asthma should

raise a red flag that a child may be at risk for developing asthma.

There is now some evidence of different phenotypes related to

genotypes, which can trigger different thoughts about treatment. For

example, patients respond to steroids in different ways. Although

patients who are not doing well may not be taking the prescribed

inhaled steroid or may be taking it incorrectly, some have

alterations in steroid-receptor binding, which can block the effect

of the drug. Markers of inflammation, such as exhaled nitric oxide,

are being studied as predictors of response to inhaled steroids.

Finally, the dose may be inadequate, or the patient may not be

administering the drug properly.

Among the newer treatment options for patients with severe asthma is

combination therapy including an inhaled steroid and a long acting

b2-agonist. Macrolide antibiotics are receiving renewed interest

because Chlamydia and Mycoplasma are appearing in lung biopsies of

severe asthmatics.