For decades, asthma experts have told their medical colleagues to prescribe daily use of low-dose corticosteroid inhalers to treat mild, persistent asthma. This recommendation has been enshrined in international guidelines. When patients do not improve on this regimen, doctors sometimes assume they are not using their inhalers as prescribed. But what if conventional asthma treatment is wrong?
Dr. Stephen Lazarus is a pulmonologist and a professor of medicine at the University of California, San Francisco. He is the lead author of an article in the New England Journal of Medicine (May 23, 2019). It is shaking up basic assumptions about asthma treatment.
Mometasone (Asmanex), Tiotropium (Spiriva) or Placebo?
The researchers randomly assigned nearly 300 asthma patients to one of three treatment groups. Some got an inhaled steroid called mometasone. Others got an inhaled anticholinergic drug to open airways called tiotropium. The final group received an inhaled placebo.
Before the study began, the investigators monitored all patients for the presence of eosinophils in their mucus. These white blood cells are elevated when people have allergic reactions.
The researchers were surprised to discover that nearly three-fourths of their participants had low eosinophil levels despite persistent asthma symptoms. Among these individuals, neither mometasone nor tiotropium performed better than placebo at preventing troublesome asthma symptoms.
Levels of such white blood cells in the lungs are a measure of different kinds of lung inflammation. When eosinophil levels are high, asthma treatment with steroid inhalers works better.
Different Kinds of Asthma:
Asthma treatment has revolved around the assumption that most asthma is the same: inflammation in the respiratory tract leads to constriction of airways. Symptoms can include wheezing, coughing, a sensation of chest tightness and breathing difficulties.
What causes the initial inflammation that sets off the cascade of events leading to shortness of breath? Allergies are often blamed. Some people are sensitive to pollen, cats or dogs, dust mites, latex or chemical fumes. Others react to exercise, cold air or respiratory tract infections like colds or flu.
Turning Asthma Treatment Upside Down:
The work of Dr. Lazarus and others suggests that the kind of inflammation underlying asthma can make a huge difference in treatment outcome.
“’An astonishingly high proportion of people with mild asthma’ have a type of inflammation which may not get better with steroid inhalers, says Dr. Lazarus. ‘If you have patients who have been prescribed steroids and they don’t seem to be responding, the solution is not to escalate the dose and give them more and more; the solution is to think of alternative ways of managing the asthma.’”
“We’re suggesting that it’s time to reevaluate what the standard recommended form of treatment is for these milder patients.
“We may be giving people steroids, subjecting them to potential adverse effects and the increased costs, without a significant clinical benefit.”
What Are Some Steroid Side Effects?
Let’s be honest. Inhaled corticosteroids are way safer than oral steroids. Taking prednisone pills for long periods of time can have serious consequences, though there are times when oral medicine is necessary for asthma treatment and other serious inflammatory conditions. You can learn more about this dilemma at this link:
Inhaled steroids are not innocuous, however. Hoarseness, throat irritation, headache, bone loss, cataracts, glaucoma, respiratory tract infections and thinning of the skin are potential complications of asthma treatment with inhaled corticosteroids.
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Here is one complication of inhaled steroids that may not always be mentioned:
When Inhaled Steroids Are Appropriate Asthma Treatment:
In the study conducted by Dr. Lazarus and his colleagues, those with high levels of eosinophils responded significantly better to mometasone than to placebo. That suggests that some patients do well with inhaled steroids, while those with low eosinophils may not.
Which Asthma Treatment Is Best?
Determining eosinophil levels in lung mucus is not part of the standard asthma treatment workup. Most clinicians do not perform this kind of test. It may, however, determine who will do better on inhaled steroids and who might improve on a different kind of asthma treatment.
A different study in the New England Journal of Medicine (May 23, 2019) tested an “as-needed” approach to asthma treatment. Instead of regular daily asthma treatment, doctors tested the benefits of intermittent therapy. In doctorspeak, they were comparing a daily “maintenance” approach to a patient-determined treatment regimen.
There were three groups of patients with mild asthma. One used two puffs from an albuterol inhaler as needed. The maintenance group was told to use two puffs of the steroid inhaler budesonide daily and add albuterol as needed. The third group used a combo inhaler (albuterol plus budesonide, known as Symbicort) only as needed. The people using Symbicort “as needed” had the best outcome.
The as-needed approach to asthma treatment will scare a lot of clinicians. They have been taught that daily maintenance therapy is the best way to treat most asthma patients, even those with mild symptoms. We will leave this debate to the professionals.
Dr. Lazarus has challenged many pulmonologists with his study comparing inhaled steroids or tiotropium to placebo in patient with mild asthma and low eosinophil levels. You may wish to bring his intriguing study in the New England Journal of Medicine to the attention of your doctor.
Another Asthma Treatment: Antibiotics?
Yet a different approach is generally reserved for hard-to-treat asthma. David Hahn, MD, MPH, has written a fascinating book titled “A Cure for Asthma? What Your Doctor Isn’t Telling You–and Why.” Dr. Hahn has spent decades trying to discover the cause of difficult-to-treat breathing problems. His research has revealed that many people are infected with a nasty bacterium called Chlamydia pneumoniae. His data suggest that this bug lingers in the lungs and can trigger inflammation and airway constriction. Dr. Hahn believes that many people can overcome the infection with the proper course of antibiotics.
“Adults with persistent symptomatic asthma experience fewer asthma exacerbations and improved quality of life when treated with oral azithromycin for 48 weeks. Azithromycin might be a useful add-on therapy in persistent asthma.”
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” Read Joe's Full Bio.
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Lazarus SC et al, "Mometasone or tiotropium in mild asthma with a low sputum eosinophil level." New England Journal of Medicine, May 23, 2019. DOI: 10.1056/NEJMoa1814917
Beasly R et al, "Controlled trial of budesonide-formoterol as needed for mild asthma." New England Journal of Medicine, May 23, 2019. DOI: 10.1056/NEJMoa1901963
Gibson PG et al, "Effect of azithromycin on asthma exacerbations and quality of life in adults with persistent uncontrolled asthma (AMAZES): A randomised, double-blind, placebo-controlled trial." Lancet, Aug. 12, 2017. DOI: 10.1016/S0140-6736(17)31281-3
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