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IN THIS ARTICLE Environmental control measures   
If your diet is deficient in iron, calcium, zinc or phosphate, you are more susceptible to lead poisoning. more...  OTHER TOPICS Exercise, nutrition and health |
How Best to Manage Your Asthma
E. Neil Schachter, M.D. The widespread obstruction of airways that causes asthma symptoms can be extremely frightening to patients, their families and friends. Fortunately, the obstruction is, usually, reversible--either spontaneously or with therapy. Medical scientists now believe that asthma is characterized by chronic inflammation and is active even when you have no symptoms. As a result of the continuous airway inflammation, irritants such as air pollutants or allergens produce, from time to time, medical consequences for the asthmatic.1 Many mechanisms cause asthma and they are not well understood. For practical reasons, we distinguish asthma associated with allergies from those for which allergy plays a less prominent role. Regardless of the cause, asthma is a disease that needs to be continually managed. The best way to do this is to pursue treatment through both drugs and non-pharmacologic therapies. The primary goal of therapy is to reduce airway inflammation overall and manage flare-ups. Even though asthma is a disease of intricate physiology and genetics, it is clear that the environment -- the setting in which it occurs -- is very important. In the United States, data show that the patient's economic and social circumstances2 and the medical support system available to the patient3 are important factors affecting disability and death. An educated patient is important to managing asthma successfully. The National Institutes of Health developed for doctors and patients Guidelines for the Diagnosis and Management of Asthma.4 The guidelines emphasize that though asthma is a chronic disease, the asthmatic's understanding of their environment and prescribed regimen is central to successful management of their disease. Self Management Strategies 1. Follow the treatment plan and make sure you do not run out of medication. 2. Take the following steps to reduce anxiety: Make sure you understand the treatment plan. Make sure you have "measurement instruments" (e.g., diaries, peak flow meters) so that you can monitor the severity of your disease. Have your doctor demonstrate the use of meter-dose inhalers, spacers and other respiratory care devices while you are in the office. 3. Become aware of the environmental irritants that have the potential to cause flare-ups as well as those you know can trigger an attack so that you can develop avoidance strategies. Here are some common sense things you can do:
Pharmacologic Management For most asthmatics, pharmacologic management of asthma can be safe and effective, reducing symptoms, improving activity tolerance, preventing attacks and maintaining near normal lung function. Tailoring of individual regimens will depend on patient preferences, compliance issues, side-effects, convenience and cost. The two main therapeutic classes of drugs for asthma are anti-inflammatory agents and bronchodilators. Anti-inflammatory agents reduce airway swelling and mucous secretion, while bronchodilators relax airway constriction. Anti-inflammatory Agents For the treatment of acute short-term asthma flare-ups, I usually administer a short course (7-14 days) of oral or injected steroids. Corticosteroids (Table 1) are the most effective/reliable anti-inflammatory agents. A steroid burst, over one to two weeks, is usually effective in treating severe acute flare-ups (e.g., prednisone 40 to 80 mg daily in adults or 1-2 mg/kg in children initially, which may be followed by tapering).
For stable asthma, inhaled steroids are the anti-inflammatory agents of choice and are well tolerated over extended periods with minimal systemic effects. Some preparations, however, particularly those used at high doses, may suppress the pituitary gland and, in children, may retard growth. The concern about these side-effects, with long-term use of nebulized (meter dose inhaler administered) corticosteroids, requires that alternative anti-inflammatory agents ("adjuncts") be considered: Anti-leukotrience agents (Zileuton®, Accolate® and Singulair®), cromolyn sodium(available as a spray or as a powder) for inhalational use or nedocromil sodium available as a spray. Anti-leukotriene agents are oral anti-inflammatory agents that are currently recommended for the management of mild to moderate disease. Bronchodilator Therapy Bronchodilators are used for the rapid control of asthma symptoms. The following three classes of bronchodilator therapy (Table 2) are currently used for the management of asthma.
1: Asthma is not an FDA approved indication for these agents. 2: A=aerosol, O=oral, P=parenteral 3: S=short (<2 hours), I=intermediate (4-6 hours), L=long (12 hours or greater) While oral and parenteral bronchodilators do afford some flexibility, and are said to insure better compliance, these agents are most commonly administered by aerosol to reduce systemic side-effects. Methylxanthines, however, are not effective when given as an aerosol and are much less popular at this time. General Approach to Management (Adults)4,5 The approach to management is summarized in Table 3 below.
* With greater variability consider methylxanthines, long acting beta agonist by inhaler (for example, salmeterol [Serevent®]), steroid burst. NOTE: All these regimens call for the regular use of anti-inflammatory agents (primarily steroid inhalers), but recommend bronchodilators only as needed. If You Are Pregnant The treatment of asthma in pregnancy follows the same general principles as that of the non-pregnant asthmatic. It is generally desirable for the welfare of both mother and child to keep the patient relatively free from asthma. Inhaled medications are preferred because less of these medicines will reach the fetus but they should be prescribed if the asthma is not controlled by inhaled medication. Table 4 lists the FDA risk factor category of commonly used asthma medications. It needs to be stressed that the greatest risk to the fetus is uncontrolled asthma.
A=Controlled studies no risk B=No evidence of risk in humans C=Risk cannot be ruled out D=Positive evidence of risk X=Contraindicated in pregnancy In Development Many new approaches and agents for the treatment of asthma have recently become available or are being tested: 6 - 14
Others: 15 - 22
Patient education, in particular, the avoidance and removal of environmental irritants, is the foundation of asthma management. Any program must be tailored to the patient's individual needs. Complementing this approach is an effective array of agents available to manage both the inflammatory component of asthma, as well as its acute flare-ups. All degrees of asthma require anti-inflammatory therapy. The agents of choice in this category are inhaled steroids. Alternatives exist in the form of cromolyn, nedocromil and, most recently, anti-leukotriene agents. Acute flare-ups require bronchodilator agents administered for symptoms.
References 1. Shelhamer JH, Levine SJ, Wu T, Jacoby DB, Kaliner MA, Rannard SI: Airway Inflammation. Ann. Int. Med 1995; 123:288-304. return 2. Montgomery LE, Liely JL, Pappos G: The effects of poverty, race and family structure on US Children's Health: Data from the NHIS 1978 through 1980 and 1989 through 1991. Am J Public Health 1996; 86:1401-05. return 3. Mayo PH, Weinberg BJ, Kramer B, Richman J, Seibert-Choi OS, Rosen MJ: Results of a program to improve the process of impatient care of adult asthmatics. Chest 1996; 110:48-52. return 4. National Asthma Education Program: Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma #2. 1997 NIH Publication No. 97-4051. return 5. British Thoracic Society: Guidelines for the management of asthma: a summary BMJ 1993; 306:776-82. return 6. Ogirala-RG, Starm TM, Aldrich TK, Meller FF, Pacia EB, Keane AM, Finkel RI: Single high dose intramuscular triamcinolone acetomide versus weekly oral methatrexate in life threatening asthma. Am J Respir Cri Care Med 1995; 152:1461-6. return 7. Lock SH, Kay AB, Barnes NC: Double blind, placebo controlled study of cyclosporin A as a corticosteroid spaning agent in corticosteroid dependant asthma. Am J Respir Crit Care Med 1996; 153:509-14. return 8. Honma M, Tamura G, Shirato K, Takishima T: Effect of an oral gold compound on non-specific bronchial hypreresponsiveness in mild asthma. Thorax 1994; 49:649-51. return 9. Moss RB: Alternative pharmacotherapies for steroid-dependant asthma. Chest 1955; 107:817-25. return 10. Kay AB: Immunosuppressive agents in chronic severe asthma. Allergy Proc 1994; 15:147-50. return 11. Gelfand EW, Landwehr LP, Esterl B, Mazer B: Intravenous immunoglobulin: an alternative therapy in steroid-dependant allergic diseases. Clin Exp Immunol 1996; 104 Suppl 1:61-6. return 12. Groce J, Negreiros EB, Mazzei JA, Istwiz G: Allergy: A double blind, placebo controlled comparison of sodium cromoblycate and ketotifen in the treatment of childhood asthma. 1995; 50:524-7. return 13. Sivaceura A, Brugami G, Fiordi T, Areni S, Severini E, Marabini A: Troleandomycin in the treatment of difficult asthma. J Allergy Clin Immunol 1993; 92:677-82. return 14. Nelson HS, Bensch G, Pleskow WW et al. Improved bronchodilation with levalbuterol compared with racemic albuterol in patients with asthma. J Allerg Clin Immuniol 1998; 102:943-52. return 15. Witek TJ, Schachter EN: Pharmacology and Therapeutics in Respiratory Care. WB Saunders (Phil) 1994. return 16. Kelly SJ, Uri AJ, Freeland HS, Woods EJ, Schulman ES, Peters SP, Fish JE. Effects of coldicine on IgE mediated early and late airway reactions. Chest 1995; 107:985-91. return 17. Tamaoki J, Tagaya E, Sakai A, Konno K: Effects of macrolide antibiotics on neurally mediated contraction of human isolated bronchus. J Allergy Clin Immunol 1995; 95:853-9. return 18. Munyard P, Chung KF, Bush A: Inhaled frusemide and exercise-induced bronchoconstriction in children with asthma. Thorax; 1995;50:677-9. return 19. Banner KH, Page CP: Theophylline and selective phosphadiesterase inhibitors as anti-inflammatory drugs in the treatment of bronchial asthma. Eur Respir J 1995; 8:996-1000. return 20. Hunt LW, Swedlund HA, Gleich GJ: Effect of nebulized lidocaine on severe glucocorticoid-dependent asthma. Mayo Clin Proc 1996; 71:361-8. return 21. Wegner CD, Gundel RH, Letts LG: Efficacy of monoclonal antibodies against adhesion molecules in animal models of asthma. Agents and Actions Suppl 1993; 43:151-62. return 22. Kidney JC, Fuller RW, Worschell YM, Lavender EA, Chung KF, Barnes PJ: Effect of an oral potassium channel activator, BRL 38227 on airway function and responsiveness in asthmatic patients. Thorax 1993; 48:130-3. return | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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